Who Wants to Sleep Alone?

Issue 149 - July/August 2008
By Peggy O'Mara, Editor and Publisher

On May 8, the New York State Office of Children and Family Services (OCFS) launched its Babies Sleep Safest Alone campaign, inspired by the deaths of 89 infants or small children reported to the New York Statewide Central Register of Child Abuse and Maltreatment since 2006. "In all of these cases, the child was co-sleeping with a parent, sibling or caregiver," according to the OCFS. I understand that Ohio and Indiana have similar campaigns underway.

When I first heard about this campaign, I was outraged. How dare the government encroach upon our personal lives like that? I was ready to hold a public event to protest the campaign, and immediately e-mailed pediatric anthropologist Meredith Small, and James McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame; McKenna suggested a cosleep-in in Central Park.

After some reflection, I realized that New York's campaign wasn't really directed at me. Like all public health campaigns, it targets everyone in order to reach the few who might actually need to hear the message. Instead of educating parents about the dangers of bed sharing when they're drunk, stoned, medicated, or exhausted, or cautioning against bed sharing with caregivers and siblings, it's easier simply to discourage the practice altogether. The recommendation, however, fails to differentiate between parents with limited resources who bed-share out of necessity, those who do so out of neglect, and those who intentionally bed-share in what they believe to be the best interests of their child.

Before we proceed, it is important to clarify the vocabulary. While the New York State campaign uses cosleeping to mean sleeping with one's baby, this is actually called bed sharing. Cosleeping simply means sleeping in close proximity to your baby, something that both New York State and the American Academy of Pediatrics actually recommend. Some families who cosleep bring the baby into bed with them, some have a side cart on their bed, and others put a portable crib or basinet next to it.

These terms have become politically charged in the last decade as the increase in breastfeeding has been accompanied by an increased acceptability of bed sharing. Bed sharing allows breastfeeding mothers to be less disturbed by nighttime feedings, and thus to get more sleep. Distinguishing between bed sharing and cosleeping, however, can lead to a false dichotomy—in reality, one practice often leads seamlessly to the other. Most people do both: Mom brings the baby into bed to nurse and both fall asleep. The family bed is something born of necessity, not necessarily something that most parents set out to have.

At the root of this debate lie different and contradictory philosophies about what is in the best interests of the child. Some psychologists see bed sharing with children as aberrant in any form, while others see it as an important part of the attachment process. On each side are the usual prejudices and vested interests that can make that side appear "right" to its proponents, and the other side "wrong." Different studies show different results. And, finally, the important distinction between breastfeeding and bottle-feeding mothers in regard to bed sharing is not recognized.

Because of our national superiority complex, we often believe that if something is true here in the US, it must be right everywhere. In the area of infant sleep, this couldn't be further from the truth. According to pediatric anthropologist Meredith Small, the US is unique in being the only nation in the world in which babies are routinely put in their own beds in their own rooms. Small reports on one study that showed that, in 67 percent of the world's cultures, children sleep in the company of others. In another survey of 172 societies, all infants in all cultures do some bed-sharing at night, even if only for a few hours.

Americans didn't talk much about this until 1978, when Tine Thevenin's book The Family Bed was published. Until then, the family bed had been a family secret embraced only by pioneers of natural living and breastfeeding. In 1981, the New York Times went so far as to refer to it as a "medieval" practice. Despite such prejudice, the family bed came out of the closet, and more Americans were willing to admit to what they'd long done secretly.

National Center for Health Statistics data from the state Pregnancy Risk Assessment Monitoring System (PRAMS) from 1991 to 1999 showed that 25.8 percent of new mothers slept with their babies "almost always," and 41.9 percent "sometimes" did, for a combined total of 67.7 percent of new moms who always or sometimes sleep with their babies.

Despite, or perhaps because of, the prevalence of bed sharing in the US, about ten years ago there began to be a more public debate about the family bed. It was then that the terms cosleeping and bed sharing, once considered two overlapping aspects of the same practice, began to be understood and defined as describing two different practices.

This mincing of words has been going on since September 1999, when the US Consumer Product Safety Commission (CPSC) made its first pronouncement specifically cautioning against cosleeping (they actually meant bed sharing). In May 2002, the CPSC issued a statement describing the hidden hazards of adult beds. Like New York State, the CPSC based its recommendations on retrospective analyses—in the case of the CPSC, death certificates—and not on any other scientific evidence.

Because of Mothering's concern that the CPSC was ignoring the relevant evidence and needlessly frightening parents, in 2002 we asked the world's top infant-sleep researchers to write for us on the subject, and we published their responses in a special issue, "Sleeping with Your Baby: The World's Top Scientists Speak Out" (Mothering no. 114, September-October 2002). Here is a sampling of what they said:

James J. McKenna, PhD, is a professor of ?anthropology, and the department chair and director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame, where he observes mother-infant pairs during sleep. His research on these observations demonstrates that the human infant's body is adapted only to the mother's body, and that cosleeping with nighttime breastfeeding remains potentially lifesaving.

Tina Kimmel, MSW, MPH, PhD, analyzed the data on which the CPSC based its recommendation against bed sharing, and discovered that it was actually more than twice as safe for an infant to sleep in an adult bed as it was to sleep alone in a crib. Looked at another way, Kimmel's data show that crib sleeping is 2.37 times more risky than bed sharing.

Finally, Peter Fleming, CBE, PhD, MBChB, FRCP, FRCPCH, professor of infant health and developmental physiology at the University of Bristol and a pediatrician at the UK's Royal Hospital for Children, Bristol, is considered the top expert in the world on Sudden Infant Death Syndrome (SIDS). He recommends sleeping in the same room with the baby and, if breastfeeding, bringing the baby into bed to feed. He thinks that these and other recommendations will significantly reduce the risk of SIDS. Not all SIDS organizations agree. It is clear that fear of SIDS is a powerful emotional contributor to both the New York State OCFS and CPSC campaigns—groups such as First Candle (formerly SIDS Alliance) warn against bed sharing, implying that it is a possible cause of SIDS.

One reason for these radically different recommendations may be the failure to distinguish not only between intentional and nonintentional bed sharing, but also between breastfeeding and bottle-feeding mother-infant pairs. Helen Ball, Senior Lecturer in Anthropology and director of the Parent-Infant Sleep Lab at Durham University, UK, discovered some significant differences between these two groups in research published in 2004 and 2005. Ball's observations were consistent with the observations of previous sleep-lab studies in regard to mother-infant bed-sharing behaviors. Significant differences were found, however, between formula and breastfed infants. Breastfeeding mothers shared a bed with their infants in a characteristic manner that provides several safety benefits. For example, their sleep positions are oriented to one another, and they experience synchronous arousal during sleep; that is, they wake up spontaneously at the same time for feedings. Formula-feeding mothers, on the other hand, shared a bed in a more variable and thus unpredictable manner, with possible negative consequences for infant safety.

Another reason for these radically different perspectives is that the New York State and CPSC recommendations are based only on epidemiological data within their agencies. It's perplexing that prospective studies such as McKenna's and Ball's—actual observations of mother-infant pairs in sleep labs—are routinely ignored by the government when making recommendations about infant sleep.

All of this rhetoric only confuses parents. Faced with avoidable infant deaths, the New York State OCFS chose to intimidate rather than to educate. I appreciate the challenges faced by OCFS, but parents must take a different tack. Sometimes, public health recommendations can be taken with a grain of salt. Sometimes they are wrong.

As a society, we have learned a powerful lesson regarding certain children's susceptibility to mandatory vaccines. Once outcasts, parents who have fought for vaccine safety are now heroes. While the successful government Back to Sleep program has resulted in a drop in SIDS deaths, it has also resulted in an increase in Positional Plagiocephaly, or flattened-head syndrome. Vitamin D, now recommended for all babies, is an example of public policy instituted to repair the damage caused by earlier public policy. Because of fear of skin cancer from direct exposure to sunlight, we recommend sunscreen for babies. This results in vitamin D deficiency in babies, which in turn requires supplements.

A responsible parent might conscientiously object to vaccines, might want to select only specific vaccines, might delay a child's vaccinations, might have a child be given only one vaccine at a time—or might follow the standard vaccine schedule exactly.

Once her baby can lift his head, a responsible parent might vary her baby's position so that he sometimes sleeps on his back, sometimes on his side, and sometimes on his stomach.

A responsible parent might forgo the supplement and decide that it is safe to expose her breastfed baby to the sun for the 20 minutes a week it takes to get sufficient vitamin D.

In her own and her infant's best interests, a responsible parent might bed-share in the full knowledge that the evidence supports her decision, even encourages it.

Knowing that a parent is the only one ultimately responsible for her child, a responsible parent might just think for herself.