Bedsharing promotes breastfeeding

Randomised trial of infant sleep location on the postnatal ward

OBJECTIVE

To determine whether postnatal mother-infant sleep proximity affects breastfeeding initiation and infant safety.

DESIGN

Randomised non-blinded trial analysed by intention to treat.

SETTING

Postnatal wards of the Royal Victoria Hospital (RVI), Newcastle upon Tyne, UK.

PARTICIPANTS

64 newly delivered mother-infant dyads with a prenatal intention to breastfeed (vaginal deliveries, no intramuscular or intravenous opiate analgesics taken in the preceding 24 h).

INTERVENTION

Infants were randomly allocated to one of three sleep conditions: baby in mother's bed with cot-side; baby in side-car crib attached to mother's bed; and baby in stand-alone cot adjacent to mother's bed.

MAIN OUTCOME MEASURES

Breastfeeding frequency and infant safety observed via night-time video recordings.

RESULTS

During standardised 4-h observation periods, bed and side-car crib infants breastfed more frequently than stand-alone cot infants (mean difference (95% confidence interval (CI)): bed v stand-alone cot = 2.56 (0.72 to 4.41); side-car crib v stand-alone cot = 2.52 (0.87 to 4.17); bed v side-car crib = 0.04 (-2.10 to 2.18)). No infant experienced adverse events; however, bed infants were more frequently considered to be in potentially adverse situations (mean difference (95% CI): bed v stand-alone cot = 0.13 (0.03 to 0.23); side-car crib v stand-alone cot = 0.04 (-0.03 to 0.12); bed v side-car crib = 0.09 (-0.03-0.21)). No differences were observed in duration of maternal or infant sleep, frequency or duration of assistance provided by staff, or maternal rating of postnatal satisfaction.

CONCLUSION

Suckling frequency in the early postpartum period is a well-known predictor of successful breastfeeding initiation. Newborn babies sleeping in close proximity to their mothers (bedding-in) facilitates frequent feeding in comparison with rooming-in. None of the three sleep conditions was associated with adverse events, although infrequent, potential risks may have occurred in the bed group. Side-car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward.

Co-sleeping, an ancient practice: issues of the past and present, and possibilities for the future

Co-sleeping-infants sharing the mother's sleep space-has prevailed throughout human evolution, and continued over the centuries of western civilization despite controversy and blame of co-sleeping mothers for the deaths of their infants. By the past century, "crib death" was recognized, later identified as Sudden Infant Death Syndrome (SIDS), and generally found to occur more frequently during bed sharing. Pediatricians warned parents of the dangers of SIDS and other risks of bed sharing, and the frequency of bed sharing decreased markedly over the years. However, during recent decades, bed sharing began to increase, though major issues were raised, including: whether bed sharing actually exacerbates or is protective against the occurrence of SIDS, whether the practice facilitates breast feeding, whether bed sharing is beneficial for an infant's development, and other concerns. Dissention may soon be diminished by use of a crib which opens at the mother's bed-side and is becoming a popular approach to mother-and-infant closeness through the night.

Differences in infant and parent behaviors during routine bed sharing compared with cot sleeping in the home setting

OBJECTIVES

To observe the behavior of infants sleeping in the natural physical environment of home, comparing the 2 different sleep practices of bed sharing and cot sleeping quantifying to factors that have been identified as potential risks or benefits.

METHODS

Forty routine bed-sharing infants, aged 5-27 weeks were matched for age and season of study with 40 routine cot-sleeping infants. Overnight video and physiologic data of bed-share infants and cot-sleep infants were recorded in the infants' own homes. Sleep time, sleep position, movements, feeding, blanket height, parental checks, and time out of the bed or cot were logged.

RESULTS

The total sleep time was similar in both groups (bed-sharing median: 8.6 hours; cot-sleeping median: 8.2 hours). Bed-sharing infants spent most time in the side position (median: 5.7 hours, 66% of sleep time) and most commonly woke at the end of sleep in this position, whereas cot-sleeping infants most commonly slept supine (median: 7.5 hours, 100%) and woke at the end of sleep in the supine position. Prone sleep was uncommon in both groups. Head covering above the eyes occurred in 22 bed-sharing infants and 1 cot-sleeping infant. Five of these bed-sharing infants were head covered at final waking time, but the cot-sleeping infant was not. Bed-sharing parents looked at or touched their infant more often (median: 11 vs 4 times per night) but did not always fully wake to do so. Movement episodes were shorter in the bed-sharing group as was total movement time (37 vs 50 minutes respectively), whereas feeding was 3.7 times more frequent in the bed-sharing group than the cot-sleeping group.

CONCLUSIONS

Bed-share infants without known risk factors for sudden infant death syndrome (SIDS) experience increased maternal touching and looking, increased breastfeeding, and faster and more frequent maternal responses. This high level of interaction is unlikely to occur if maternal arousal is impaired, for example, by alcohol or overtiredness. Increased head covering and side sleep position occur during bed-sharing, but whether these factors increase the risk of SIDS, as they do in cot sleeping, requires further investigation.

The relation between child death and child maltreatment

The death of a child is a sentinel event in a community, and a defining marker of a society's policies of safety and health. Child death as a result of abuse and neglect is a tragic outcome that occurs in all nations of the world. The true incidence of fatal child abuse and neglect is unknown. The most accurate incidence data of such deaths have been obtained from countries where multi-agency death review teams analyse the causes of child fatalities, as is done in the United States and Australia.

The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk

There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping. The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant's sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of "back to sleep," and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDS-related issues and proposes new recommendations for further reducing SIDS risk.

Bedsharing and maternal smoking in a population-based survey of new mothers

OBJECTIVE

Sudden infant death syndrome (SIDS) remains the number 1 cause of postneonatal infant death. Prone infant sleep position and maternal smoking have been established as risk factors for SIDS mortality. Some studies have found that bedsharing is associated with SIDS, but, to date, there is only strong evidence for a risk among infants of smoking mothers and some evidence of a risk among young infants of nonsmoking mothers. Despite the lack of convincing scientific evidence, bedsharing with nonsmoking mothers remains controversial. In some states, nonsmoking mothers are currently being told that they should not bedshare with their infants, and mothers of infants who died of SIDS are told that they caused the death of their infant because they bedshared. The objective of this study was to explore the relationship between maternal smoking and bedsharing among Oregon mothers to explore whether smoking mothers, in contrast to nonsmoking mothers, are getting the message that they should not bedshare.

METHODS

Oregon Pregnancy Risk Assessment Monitoring System surveys a stratified random sample, drawn from birth certificates, of women after a live birth. Hispanic and non-Hispanic black, non-Hispanic Asian/Pacific Islander and non-Hispanic American Indian/Alaskan Native women, and non-Hispanic white women with low birth weight infants are oversampled to ensure sufficient numbers for stratified analysis. The sample then was weighted to reflect Oregon's population. In 1998-1999, 1867 women completed the survey (73.5% weighted response). The median time from birth to completion of the survey was 4 months. Women were asked whether they shared a bed with their infant "always," "almost always," "sometimes," or "never." Frequent bedsharing was defined as "always" or "almost always"; infrequent was defined as "sometimes" or "never."

RESULTS

Of all new mothers, 35.2% reported bedsharing frequently (always: 20.5%; almost always: 14.7%) and 64.8% infrequently (sometimes: 41.4%; never: 23.4%). Bedsharing among postpartum smoking mothers was 18.8% always, 12.6% almost always, 45.1% sometimes, and 23.6% never; this was not statistically different from among nonsmoking mothers. Results for prenatal smokers were similar. When stratified by race/ethnicity, there was no association between smoking and bedsharing in any racial or ethnic group. In univariable and multivariable logistic regression, there were no statistical differences in frequent or any bedsharing among either prenatal or postpartum smoking mothers compared with nonsmokers; the adjusted odds ratio for postpartum smokers who frequently bedshared was 0.73 (95% confidence interval [CI]: 0.42-1.25) and for any bedsharing was 1.05 (95% CI: 0.57-1.94). Results for prenatal smoking were similar. This is the first US population-based study to look at the prevalence of bedsharing among smoking and nonsmoking mothers. Bedsharing is common in Oregon, with 35.2% of mothers in Oregon reporting frequently bedsharing and an additional 41.4% sometimes bedsharing. There was no significant association between smoking and bedsharing for either prenatal or postpartum smokers among any racial or ethnic group. Smoking mothers were as likely to bedshare as nonsmoking mothers. The frequency of bedsharing in Oregon was similar to estimates from other sources. Our study has the advantage of being a population-based sample drawn from birth certificates, weighted for nonresponse.

CONCLUSIONS

Although a number of case series have raised concerns about the safety of mother-infant bedsharing, even among nonsmoking mothers, this has not yet been confirmed by careful, controlled studies. There have been 9 large-scale case-control studies of the relationship between bedsharing and SIDS. Three case-control studies did not stratify by maternal smoking status, but found no increased risk for SIDS. Six case control studies reported results stratified by maternal smoking status: 1 study, while asserting an association, provided an unexplained range of univariable odds ratios without CIs; 3 found no increased risk for older infants of nonsmoking mothers; and 2 found a risk only for infants <8-11 weeks of age. Despite the preponderance of evidence that bedsharing by nonsmoking mothers does not increase the risk for SIDS among older infants, the recent specter of bedsharing as a cause of SIDS, based on uncontrolled case series and medical examiners' anecdotal experience, has led some medical examiners to label a death "suffocation" or "overlay asphyxiation" simply because the infant was bedsharing at the time of death. This "diagnostic drift" may greatly complicate future studies of the relationship between bedsharing and SIDS. Epidemiologic evidence shows that there is little or no increased risk for SIDS among infants of nonsmoking mothers but increased risk among infants of smoking mothers and younger infants of nonsmoking mothers. It seems prudent to discourage bedsharing among all infants <3 months old. Young infants brought to bed to be breastfed should be returned to a crib when finished. It would be worthwhile for other researchers to reanalyze their previous data to evaluate the consistency of the interaction of young infant age and bedsharing. Large controlled studies that include infants who are identified as dying from SIDS, asphyxia, suffocation, and sudden unexplained infant death, analyzed separately and in combination, are needed to resolve this and other issues involving bedsharing, including the problem of diagnostic drift. Recommendations must be based on solid scientific evidence, which, to date, does not support the rejection of all bedsharing between nonsmoking mothers and their infants. Cribs should be available for those who want to use them. Nonsmoking mothers should not be pressured to abstain from bedsharing with their older infants; they should be provided with accurate, up-to-date scientific information. Infants also should not co-sleep with nonparents. In Oregon, if not elsewhere, the message that smoking mothers should not bedshare is not being disseminated effectively. Because it is not known whether the risk caused by smoking is associated with prenatal smoking, postpartum smoking, or both, bedsharing among either prenatal or postpartum smokers should be strongly discouraged. Much more public and private effort must be made to inform smoking mothers, in culturally competent ways, of the very significant risks of mixing bedsharing and smoking. Public health practitioners need to find new ways to inform mothers and providers that smoking mothers should not bedshare and that putting an infant of a nonsmoking mother to sleep in an adult bed should be delayed until 3 months of age.

Risk factors associated with sudden unexplained infant death: a prospective study of infant care practices in Kentucky

OBJECTIVE

To ascertain the prevalence of infant care practices in a metropolitan community in the United States with attention to feeding routines and modifiable risk factors associated with sudden unexplained infant death (specifically, prone sleeping position, bed sharing, and maternal smoking).

METHODS

We conducted an initial face-to-face meeting followed by a telephone survey of 189 women who gave birth at a level I hospital in Kentucky between October 14 and November 10, 2002, and whose infants were placed in the well-infant nursery. The survey, composed of questions pertaining to infant care practices, was addressed to the women at 1 and 6 months postpartum.

RESULTS

A total of 185 (93.9%) women participated in the survey at 1 month, and 147 (75.1%) mothers contributed at 6 months. The racial/ethnic composition of the study was 56.1% white, 30.2% black, and 16.4% biracial, Asian, or Hispanic. More than half of the infants (50.8%) shared the same bed with their mother at 1 month, which dramatically decreased to 17.7% at 6 months. Bed sharing was significantly more common among black families compared with white families at both 1 month (adjusted odds ratio [OR]: 5.94; 95% confidence interval [CI]: 2.71-13.02) and 6 months (adjusted OR: 5.43; 95% CI: 2.05-14.35). Compared with other races, white parents were more likely to place their infants on their back before sleep at both 1 and 6 months. Black parents were significantly less likely to place their infants on their back at 6 months compared with white parents (adjusted OR: 0.14; 95% CI: 0.06-0.33). One infant succumbed to sudden infant death syndrome at 3 months of age, and another infant died suddenly and unexpectedly at 9 months of age. Both were bed sharing specifically with 1 adult in the former and with 2 children in the latter.

CONCLUSIONS

Bed sharing and prone placement were more common among black infants. Breastfeeding was infrequent in all races. This prospective study additionally offers a unique perspective into the risk factors associated with sudden infant death syndrome and sudden unexplained infant death associated with bed sharing by examining the survey responses of 2 mothers before the death of their infants combined with a complete postmortem examination, scene analysis, and historical investigation.

Modifiable risk factors for SIDS in Germany: results of GeSID

BACKGROUND

The incidence of sudden infant death syndrome (SIDS) has been falling in Germany over the last decade. However, little is known about the prevalence and the importance of well-known risk factors in Germany since a local prevention campaign in 1992.

DESIGN

A 3-y, population-based, case-control study was conducted in half of Germany, consisting of 333 cases. All sudden and unexpected deaths in infancy, if they fitted the inclusion criteria, were included in the study. Parental interview was carried out soon after the death, and three living control infants, matched for age, gender, region and sleep time, were recruited.

RESULTS

The prevalence of placing infants prone to sleep was only 4% in the control group, but this was associated with a markedly increased risk of SIDS (adjusted odds ration, aOR=6.08). Other modifiable risk factors for SIDS were: maternal smoking during pregnancy, breastfeeding for less than 2 wk (aOR=1.71) and co-sleeping (aOR=2.71), while using a pacifier during the last sleep reduced the risk (aOR=0.39).

CONCLUSIONS

Previously recognized risk factors for SIDS also occur in Germany. Despite knowledge about the major modifiable risk factors for SIDS, these factors are still present in Germany. To reduce the incidence of SIDS in Germany, a continued effort is needed to inform all parents about preventable risk factors for SIDS.

Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding

There has been much controversy over whether infants should co-sleep or bedshare with an adult caregiver and over whether such practises increase the risk of SIDS or fatal accident. However, despite opposition from medical authorities or the police, many western parents are increasingly adopting night-time infant caregiving patterns that include some co-sleeping, especially by those mothers who choose to breast feed. This review will show that the relationships between infant sleep patterns, infant sleeping arrangements and development both in the short and long term, whether having positive or negative outcomes, is anything but simple and the traditional habit of labelling one sleeping arrangement as being superior to another without an awareness of family, social and ethnic context is not only wrong but possibly harmful. We will show that there are many good reasons to insist that the definitions of different types of co-sleeping and bedsharing be recognised and distinguished. We will examine the conceptual issues related to the biological functions of mother-infant co-sleeping, bedsharing and what relationship each has to SIDS. At very least, we hope that the studies and data described in this paper, which show that co-sleeping at least in the form of roomsharing especially with an actively breast feeding mother saves lives, is a powerful reason why the simplistic, scientifically inaccurate and misleading statement 'never sleep with your baby' needs to be rescinded, wherever and whenever it is published.

Investigation of sudden infant deaths in the State of Maryland (1990–2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African-American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.

Bed-sharing and the infant's thermal environment in the home setting

AIMS

To study bed-sharing and cot-sleeping infants in the natural setting of their own home in order to identify differences in the thermal characteristics of the two sleep situations and their potential hazards.

METHODS

Forty routine bed-sharing infants and 40 routine cot-sleeping infants aged 5-27 weeks were individually matched between groups for age and season. Overnight video and physiological data of bed-share infants and cot-sleeping infants were recorded in the infants' own homes including rectal, shin, and ambient temperature.

RESULTS

The mean rectal temperature two hours after sleep onset for bed-share infants was 36.79 degrees C and for cot-sleeping infants, 36.75 degrees C (difference 0.05 degrees C, 95% CI -0.03 to 0.14). The rate of change thereafter was higher in the bed-share group than in the cot group (0.04 degrees C v 0.03 degrees C/h, difference 0.01, 0.00 to 0.02). Bed-share infants had a higher shin temperature at two hours (35.43 v 34.60 degrees C, difference 0.83, 0.18 to 1.49) and a higher rate of change (0.04 v -0.10 degrees C/h, difference 0.13, 0.08 to 0.19). Bed-sharing infants had more bedding. Face covering events were more common and bed-share infants woke and fed more frequently than cot infants (mean wake times/night: 4.6 v 2.5).

CONCLUSIONS

Bed-share infants experience warmer thermal conditions than those of cot-sleeping infants, but are able to maintain adequate thermoregulation to maintain a normal core temperature.

Interaction Between Feeding Method and Co‐Sleeping on Maternal‐Newborn Sleep

BACKGROUND

Previous studies have demonstrated that breastfed newborns spend more time awake than bottle-fed newborns, breastfeeding mothers have more fragmented sleep than bottle-feeding mothers, and mother-newborn sleeping arrangements may affect the sleep/wake pattern of mother-newborn pairs.

OBJECTIVE

To address the unsolved question of whether there is an interaction between type of feeding and sleeping arrangements that affects postpartum sleep during the 4th postpartum week.

DESIGN

Correlational, two-way design using feeding method and location of newborn at night as independent variables, and sleep patterns as the dependent variables.

SETTING

Patient's home during 4th week after giving birth.

PATIENTS/PARTICIPANTS

First-time mothers and their newborns (n = 33).

MAIN OUTCOME MEASURES

Amount of total sleep, amount of night sleep, number of night awakenings, and number of sleep periods in 24 hours using a modified version of the self-report sleep instrument by Barnard and Eyres.

RESULTS

Breastfed newborns had less total sleep per day than bottle-fed newborns, and breastfeeding mothers had more sleep periods in 24 hours than bottle-feeding mothers. Breastfeeding mothers slept more than bottle-feeding mothers when co-sleeping, but bottle-feeding mothers' sleep was unaffected by location of newborn. Average total sleep for 4-week-old newborns was about 14 hours daily.

CONCLUSIONS

More sleep was obtained when breastfeeding mothers slept with the newborn. Methods or devices that allow breastfeeding mothers and newborns to sleep next to each other in complete safety need to be developed.

Frequency of bed sharing and its relationship to breastfeeding

Bed sharing has been promoted as facilitating breastfeeding but also may increase risks for sudden, unexpected infant deaths. This prospective cohort study was performed to determine the prevalence of adult and infant bed sharing and its association with maternal and infant characteristics. Demographic data were collected from 10,355 infant-mother pairs at birth hospitals in Eastern Massachusetts and Northwest Ohio, and follow-up data were collected at 1, 3, and 6 months by questionnaire. Associations with bed sharing were estimated using odds ratios and 95% confidence intervals from multiple logistic regression models while adjusting for confounding variables. At 1, 3, and 6 months, 22%, 14%, and 13% of infant-mother pairs shared a bed, respectively. On multivariate analysis, race/ethnicity and breastfeeding seemed to have the strongest association with bed sharing. These factors need to be considered in any comprehensive risk to benefit analysis of bed sharing.

Cosleeping and sleep behavior in Italian school-aged children

The prevalence and predictors of cosleeping were investigated in 901 healthy school-aged children. Parent reports on the Children's Sleep Habits Questionnaire and Child Behavior Checklist were used to assess children's sleep and behavioral problems. Regular, long-lasting cosleeping was present in 5% of our sample. Cosleepers rated higher on the Children's Sleep Habits Questionnaire total score and Bedtime Resistance, Sleep Anxiety, Nightwakings, and Parasomnias subscales than solitary sleepers. No significant behavioral problems were found in cosleepers. Regression results showed that low socioeconomic status, one parent who is a shiftworker, one-parent families, one parent who coslept as a child, prolonged breastfeeding, and previous and current sleep problems significantly predicted cosleeping. The high incidence of parents reporting having coslept as a child also suggested a lifestyle choice. Thus, cosleeping seems to reflect a parent's way to cope with sleep problems, and the long persistence of this practice may be related to the lifestyle of families.

Factors relating to the infant's last sleep environment in sudden infant death syndrome in the Republic of Ireland

AIM

To identify risk factors for sudden infant death syndrome (SIDS) in the sleeping environment of Irish infants.

METHODS

A five year population based case-control study with parental interviews conducted for each case and three controls matched for age, place of birth, and last sleep period. A total of 203 SIDS cases and 622 control infants born 1994-98 were studied.

RESULTS

In a multivariate analysis, co-sleeping significantly increased the risk of SIDS both as a usual practice (adjusted OR 4.31; 95% CI 1.07 to 17.37) and during the last sleep period (adjusted OR 16.47; 95% CI 3.73 to 72.75). The associated risk was dependent on maternal smoking (OR 21.84; 95% CI 2.27 to 209.89), and was not significant for infants who were > or =20 weeks of age (OR 2.63; 95% CI 0.49 to 70.10) or placed back in their own cot/bed to sleep (OR 1.07; 95% CI 0.21 to 5.41). The use of pillows, duvets, and bedding with tog value > or =10 were not significant risk factors when adjusted for the effects of confounding variables, including maternal smoking and social disadvantage. However, the prone sleeping position remains a significant SIDS risk factor, and among infants using soothers, the absence of soother use during the last sleep period also significantly increased the SIDS risk (OR 5.83; CI 2.37 to 14.36).

CONCLUSION

Co-sleeping should be avoided in infants who are <20 weeks of age, or whose mothers smoked during pregnancy. The prone position remains a factor in some SIDS deaths, and the relation between soother use and SIDS is a complex variable requiring further study.

Sudden infant death syndrome: overview and update

The past decade and a half has seen marked changes in the epidemiology of sudden infant death syndrome (SIDS). The avoidance of certain risk factors such as sleeping prone and cigarette smoke exposure has resulted in the death rate falling dramatically. Careful evaluation of environmental factors and endogenous characteristics has led to a greater understanding of the complexities of the syndrome. The development and implementation of death scene and autopsy protocols has led to standardization in approaches to unexpected infant deaths with increasing diagnoses of accidental asphyxia. Despite these advances, there is still confusion surrounding the diagnosis, with deaths being attributed to SIDS in many communities and countries where death scene investigations and autopsies have not been conducted. The following review provides a brief overview of the historical background, epidemiology, pathology, and pathogenesis of SIDS. Contentious issues concerning the diagnosis and current problems are discussed. Despite calls to abandon the designation, SIDS remains a viable term for infants who die in their sleep with no evidence of accident, inflicted injury, or organic disease after a full investigation has been conducted according to standard guidelines.

Outcome correlates of parent-child bedsharing: an eighteen-year longitudinal study

We report results of the first longitudinal study of outcome correlates of parent-child bedsharing. Two hundred five families in nonconventional and conventional family lifestyles have been followed since 1975. A target child in each family was followed from the third trimester of mother's pregnancy through age 18 years. Bedsharing in early childhood was found to be significantly associated with increased cognitive competence measured at age 6 years, but the effect size was small. At age 6 years, bedsharing in infancy and early childhood was not associated with sleep problems, sexual pathology, or any other problematic consequences. At age 18 years, bedsharing in infancy and childhood was unrelated to pathology or problematic consequences, nor was it related to beneficial consequences. We discuss these results in light of widespread fears of harm caused by parent-child bedsharing. We suggest that such fears are without warrant if bedsharing is practiced safely as part of a complex of valued and related family practices.

Prevalence, predictors, and attitudes toward cosleeping in an urban pediatric center

Cosleeping is the normative practice in many of the world's societies but is not endorsed by the Consumer Products Safety Commission or by the American Academy of Pediatrics. A survey was performed on 101 caregivers in an urban setting, designed to assess the prevalence of cosleeping and parental attitudes for this practice. Cosleeping rate was 88% with predictors being as follows: single parent (p=0.006), high school or less education (p=0.035), 2 or fewer rooms used for sleeping (p=0.023). A majority (65%) stated that cosleeping was acceptable.

Cosleeping in young Korean children

This study was an attempt to evaluate the present profile of parent-child cosleeping, to investigate the characteristics of those children who cosleep with their parents, and to determine the factors influencing cosleeping in Korea. Observed subjects consisted of 427 young Korean children aged 12 to 84 months. We used an interview method. The incidence of cosleeping was 377 (88.2%). Cosleeping decreased with increasing age. Cosleeping in Korean society was affected mostly by the age of parents and children, attitudes of the mother to cosleeping, and Korean traditional cultural values. The practice of cosleeping in young Korean children is very common and socially acceptable to Korean parents as a natural part of the child-rearing process. Korean family values and a cultural value system emphasizing familial bonds and interpersonal interdependence seems to act as positive reinforcing factors for the practice of cosleeping.

Sudden infant death syndrome risk factors in north Queensland: a survey of infant-care practices in Indigenous and non-Indigenous women

OBJECTIVE

To assess the prevalence of sudden infant death syndrome (SIDS) risk factors in the Indigenous and non-Indigenous community of Townsville, a large remote urban centre in north Queensland, Australia.

METHODS

Thirty Indigenous and 30 non-Indigenous women with young children were surveyed using sections of the West Australian Infancy and Pregnancy Survey 1997-1998. The prevalence of SIDS risk factors was compared between the two groups and medians and univariate associations were generated where appropriate.

RESULTS

The Indigenous women were significantly younger and more likely to be single. The median age of the infants was 8 months (range 0.3-26 months) with no difference between the two groups. Thirty-seven per cent of Indigenous infants slept prone (cf. 17% of non-Indigenous infants; P = 0.03), and 77% shared a bed (cf. 13% of non-Indigenous infants; P < 0.001). The Indigenous households had significantly more members, with 57% including extended family members (cf. 20% non-Indigenous group; P = 0.003). Fifty-three per cent of the Indigenous women smoked during pregnancy (cf. 23% of non-Indigenous women; P = 0.017), 60% were smokers at the time of the interview, and smoking occurred inside 40% of Indigenous houses (cf. 20% and 20% for non-Indigenous women, respectively; P < 0.001, 0.09).

CONCLUSION

This small survey suggests that the prevalence of SIDS risk factors is higher in the Indigenous population, and a new approach to education is needed urgently to promote SIDS awareness among Indigenous women.

Cosleeping and sudden unexpected death in infancy

CONTEXT

The practice of infants cosleeping with adults has long been the subject of controversy. Autopsy findings in cases of sudden infant death syndrome (SIDS) are usually indistinguishable from those found with unintentional or intentional suffocation, and the determination of the cause of death in cases of sudden unexpected death in infancy is often based on investigative findings and the exclusion of natural or traumatic causes.

OBJECTIVE

To further elucidate the risk of cosleeping.

METHODS

We reviewed 58 cases of sudden unexpected infant deaths. Cases were excluded if there was any significant medical history or evidence of trauma or abuse.

RESULTS

Twenty-seven of the infants were cosleeping. Eleven of these cases had been previously diagnosed as SIDS, and in 7 cases parental intoxication was documented.

CONCLUSION

Our findings support recent studies that suggest that cosleeping or placing an infant in an adult bed is a potentially dangerous practice. The frequency of cosleeping among cases diagnosed as SIDS in our study suggests that some of these deaths may actually be caused by mechanical asphyxia due to unintentional suffocation by the cosleeping adult and/or compressible bedding materials.

Changes in the epidemiological pattern of sudden infant death syndrome in southeast Norway, 1984-1998: implications for future prevention and research

AIM

To look for changes in risk factors for sudden infant death syndrome (SIDS) after decrease and stabilisation of the SIDS rate.

METHODS

Questionnaires were distributed to parents of 174 SIDS infants, dying between 1984 and 1998, and 375 age and sex matched controls in southeast Norway.

RESULTS

The proportion of infants sleeping prone has decreased, along with the decrease in SIDS rate for the region during the periods studied, but over half of the SIDS victims are still found in the prone position. As the number of SIDS cases has decreased, additional risk factors have become more significant. Thus, after 1993, a significantly increased risk of SIDS is seen when the mother smokes during pregnancy. After 1993, young maternal age carries an increased risk. Maternal smoking and young maternal age are associated with each other. For SIDS victims, an increase in the number of infants found dead while co-sleeping is seen, and the age peak between 2 and 4 months and the winter peak have become less pronounced.

CONCLUSION

Changes in risk factor profile following the decrease in SIDS rate in the early 1990s, as well as consistency of other factors, provides further clues to SIDS prevention and to the direction of further studies of death mechanisms.

Death by overlaying and wedging: a 15-year retrospective study

Overlaying, the accidental death by smothering caused by a larger individual sleeping on top of an infant, is a cause of death that has been documented for centuries. The hazard of death has been reported to be greater in infants less than 5 months of age but may occur in children up to the age of 2 years. When an adult or older child rolls on top of an infant, mechanical asphyxia results. The face may be pressed into the mattress or into the body of the sleeping adult or older child. The infant's air may be expressed, and he or she is unable to cry due to pressure on the thorax and the inability to inhale. Some pathologists and investigators believe that the victims of overlaying have no pertinent physical findings at autopsy and that any injury is indicative of inflicted trauma. Others believe that one may see contusions and abrasions from overlaying in and of itself. Wedging is another form of accidental mechanical asphyxia that may have negative autopsy findings. The prevalence of bruising, contusions, or facial and ocular petechiae is not clear. The author reviewed all pediatric forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina/Medical Examiners' Office over the past 15 years, from 1985 to 1999. Of these, all cases of overlaying, cases listed as undetermined sudden infant death syndrome versus overlaying, and wedging were included. The cases were analyzed as to victims' age, sex, race, location/bedding, bed-sharer, and whether the bed-sharer was known to have ingested drugs or alcohol before sleep. Postmortem physical findings were also reviewed, particularly for documentation of contusions, abrasions, or facial or ocular petechiae. By clarifying not only the victim, bed-sharer, and scenario but also the presence or absence of physical findings in cases of overlaying, wedging, and other accidental asphyxia, we can better categorize these cases.

Sleeping like a baby: attitudes and experiences of bedsharing in northeast England

This paper reports findings from a study that investigated infant care practices in a small population of Northeast England in order to determine whether parent-infant bedsharing is common parenting behavior. In a year-long prospective study we examined the opinions and practices of parents with regard to their infants' nighttime sleeping strategies before and after the birth of their babies. Results confirm that parents pursue a heterogeneous array of nighttime parenting strategies and that 65 percent of the sample had actually bedshared. Parents with no previous intention to do so slept with their babies for a variety of reasons. One of this study's most important findings is that babies were being brought into bed with both parents. Ninety five percent of the bedsharing infants slept with both mother and father. This study has shown that bedsharing is a relatively common parenting practice. Despite initial worries and fears, mainly concerning overlaying, some parents found bedsharing an effective option yet were covert in their practices, fearing the disapproval of health professionals and relatives.

International Child Care Practices Study: infant sleeping environment

BACKGROUND

The International Child Care Practices Study (ICCPS) has collected descriptive data from 21 centres in 17 countries. In this report, data are presented on the infant sleeping environment with the main focus being sudden infant death syndrome (SIDS) risk factors (bedsharing and infant using a pillow) and protective factors (infant sharing a room with adult) that are not yet well established in the literature.

METHODS

Using a standardised protocol, parents of infants were surveyed at birth by interview and at 3 months of age mainly by postal questionnaire. Centres were grouped according to geographic location. Also indicated was the level of SIDS awareness in the community, i.e. whether any campaigns or messages to "reduce the risks of SIDS" were available at the time of the survey.

RESULTS

Birth interview data were available for 5488 individual families and 4656 (85%) returned questionnaires at 3 months. Rates of bedsharing varied considerably (2-88%) and it appeared to be more common in the samples with a lower awareness of SIDS, but not necessarily a high SIDS rate. Countries with higher rates of bedsharing appeared to have a greater proportion of infants bedsharing for a longer duration (>5 h). Rates of room sharing varied (58-100%) with some of the lowest rates noted in centres with a higher awareness of SIDS. Rates of pillow use ranged from 4% to 95%.

CONCLUSIONS

It is likely that methods of bedsharing differ cross-culturally, and although further details were sought on different bedsharing practices, it was not possible to build up a composite picture of "typical" bedsharing practices in these different communities. These data highlight interesting patterns in child care in these diverse populations. Although these results should not be used to imply that any particular child care practice either increases or decreases the risk of SIDS, these findings should help to inject caution into the process of developing SIDS prevention campaigns for non-Western cultures.

Sudden infant death syndrome, bedsharing, parental weight, and age at death

OBJECTIVE

To assess the role of parental bedsharing in sudden infant death syndrome (SIDS)-like deaths, this study examines the hypothesis that, compared with other SIDS cases, the age distribution of deaths associated with bedsharing should be lower in younger, less vigorous infants.

METHODS

For 84 SIDS cases in Cleveland, Ohio, 1992 to 1996, age at death, maternal weight, and other risk factors for SIDS were compared for cases grouped according to bedsharing status.

RESULTS

Mean ages at death were 9.1 weeks for 30 bedsharing and 12.7 for 54 nonbedsharing cases, counting 10 with missing information as nonbedsharing. Mean pregravid weights of bedsharing mothers exceeded those of nonbedsharing mothers (84.1 vs 67.0 kg). Mean ages at death for nonbedsharing infants, bedsharing infants of smaller mothers, and bedsharing infants of larger mothers were 12.7, 10.3, and 7.6 weeks, respectively. Large maternal size did not affect age at death in the absence of bedsharing.

CONCLUSIONS

By demonstrating that among an urban population at high risk for SIDS, bedsharing is strongly associated with a younger age at death, independent of any other factors, this study provides evidence of a relationship between some SIDS-like deaths and parent-infant bedsharing, particularly if the parent is large.

CLINICAL REVIEW ARTICLE: Is changing the sleep environment enough? Current recommendations for SIDS

Sudden infant death syndrome (SIDS or cot death) was the major cause of post-neonatal infant death in many countries in the late 1970s and 1980s. There is now very strong evidence that public intervention campaigns targeting the prone sleeping position, which had been identified by epidemiological studies as a major risk factor, were followed by substantial falls in the rate of SIDS. In the present review we discuss the evidence on which current recommendations for the prevention of SIDS are based. The prone sleeping position is now clearly causally associated with SIDS. Further reductions in SIDS may be produced by recommending the back sleeping position as opposed to the side position. Maternal smoking in pregnancy and bed sharing by infants of mothers who smoke are also strongly associated with SIDS, but have been harder to influence. Paternal smoking has also been implicated, although the magnitude of the reported risk is small. Finally, breastfeeding, pacifier use and having the infant sharing the parents bedroom, but not the bed, may also reduce risk. Continued reductions in SIDS mortality will require innovative public health education to target these major risk factors, while building on the "back to sleep" approach.

[Co-sleeping and sudden infant death syndrome]

Bedsharing has recently become a controversial subject. Some authors, mainly from North America, assign to bedsharing a positive effect on the efficacy and duration of breast-feeding. Moreover, it would protect against sudden infant death syndrome (SIDS). Conversely, other studies consider bedsharing as an additional risk factor for SIDS. From the literature data, there is some evidence for an increased risk of SIDS when bedsharing is associated with maternal smoking and alcohol consumption. Bedsharing cannot be recommended as an absolutely safe practice. Breast-feeding mothers should be aware of these potential hazards.

Evidence-based care and the breastfeeding couple: key concerns

Optimal health care is based on evidence that a) no harm is done when that care is provided and that b) the care provided assists in the prevention of further problems or the resolution of the presenting problem. Too often, care provided to lactating mothers and their breastfeeding offspring lacks evidence supportive of the techniques used or care provided. This article addresses 10 common hospital-based practices and reviews documented evidence related to their effect on breastfeeding success. Concepts pertaining to the breasts and breastfeeding that require incorporation into the educational offerings of current and future health care providers are also identified.

Bed sharing patterns in a cohort of Australian infants during the first six months after birth

OBJECTIVE

To measure bed sharing (BS) activity in healthy term infants.

METHODOLOGY

The sleep-wake behaviour and place of infant sleep were recorded for infants aged between 2 and 24 weeks. Infants were then identified as BS or non bed sharing (NBS) according to each of four different definitions of bed sharing.

RESULTS

The mean proportion of infants who spent any time BS during a 24-h period was significantly greater (P < 0.05) between 2 and 12 weeks (40.9 +/- 1. 4%) than between 13 and 24 weeks (36.5 +/- 1.5%). A significantly greater proportion (P < 0.005) of infants bed shared for more than 2 h (25 +/- 1%) than for either 1-2 h (10.5 +/- 1.1%) or for less than 1 h/24 h (3.2 +/- 0.5%) during the whole study period. Each of the definitions of BS used in the study separated infants on the basis of the amount and frequency of BS activity.

CONCLUSION

: Bed sharing activity was common and varied in this cohort. It was possible, using quantitative definitions, to identify those infants who routinely bed share.

Night-time non-nutritive sucking in infants aged 1 to 5 months: relationship with infant state, breastfeeding, and bed-sharing versus room-sharing

AIM

Epidemiological studies suggest that pacifier use may be protective against SIDS but little is known of the relationship between pacifier use and other forms of non-nutritive sucking (NNS) in infancy, or of patterns of NNS during the night, when most SIDS deaths occur. We report the first longitudinal study of NNS by direct overnight observations in healthy infants in a sleep laboratory.

METHODS

Healthy, breast fed term infants (n = 10) were enrolled at birth, and sequential overnight polygraphic and infrared video recordings of infants with their mothers performed at monthly intervals from 1 to 5 months. Each month, mother baby pairs were randomized to 1 night bed-sharing (BN) then 1 room-sharing (RN), or vice versa. 'Episodes' of pacifier, own digit and mother's digit sucking (> 1 min) were identified and compared with state-matched control periods without sucking or feeding before and after each such episode.

RESULTS

329 episodes of NNS were identified in 749 h of video recording. The prevalence of pacifier sucking decreased with age, whilst digit sucking increased. Routine pacifier users rarely sucked their digits. There were temporal differences throughout the night in the distribution of different types of sucking and in infant state during and around sucking episodes. Sleeping in the 'non-routine' location was associated with a larger percentage of nights with sucking episodes and increased sleep latency. Bed sharing (routinely or on a given night) was associated with less sucking behavior and more breastfeeding. Non-nutritive sucking was not, however, associated with decreased total time breastfeeding per night or number of feeds per night.

CONCLUSION

Patterns of NNS during the night change with age and are affected by maternal proximity. Digit sucking has state modulating effects, and may be suppressed by pacifier use. Thus any benefits of pacifier use must be set against the potential loss of a self-directed ability to modulate state during the night, and possible shortening of breastfeeding duration.

Infant care practices in a metropolitan aboriginal population Bibbulung Gnarneep Team

OBJECTIVE

To describe sleeping position, room and bed-sharing, tobacco smoke exposure and infant feeding for a sample of Australian Aboriginal infants from a metropolitan area.

METHODS

Interviews with Aboriginal mothers who resided in the Perth metropolitan area and had given birth during a continuous 15-month study period. The interviews took place when the infants were approximately 6-12 weeks old and efforts were made to contact all eligible mothers. Results are presented as proportions with 95% confidence intervals.

RESULTS

Of all the eligible mothers (n = 515), 87% were contacted and 53% (n = 273) completed the interview. Of all the infants, 11% slept prone, 96% shared a room and 68% shared a bed; 65% of mothers smoked during pregnancy and 65% were smokers at the time of interview; 66% of the partners were smokers and 80% of the infants were regularly exposed to tobacco smoke; 89% of mothers initiated breast-feeding and 70% were breast-feeding at time of interview.

CONCLUSION

Prevalences of non-prone sleeping and breast-feeding are similar to the overall Western Australian population, whilst tobacco smoke exposure of the infants is markedly higher. Programs of community and family education and support are required urgently to decrease this exposure.

Sleep characteristics in children in the isolated rural African-Brazilian descendant community of Furnas do Dionísio, State of Mato Grosso do Sul, Brazil

Developmental and cultural factors affect sleep habits in childhood. The objective of this research was to determine sleep habits of children in the isolated rural African-Brazilian community of Furnas do Dionísio. Mato Grosso do Sul, Brazil. The members of this community are closely related descendants of the ex-slave Dionísio, and remained in relative geographical isolation for about a century. Sleep characteristics of 55 children (35 M; 20 F), 2 to 10 year olds, were evaluated in interviews with their mothers. The results showed that cosleeping, in the same bed with family members, was present in 80.0% of the 2-3 year olds; decreasing to 25.0% of the 8-10 year olds. Only 5.4% of the children slept alone in their own bedroom. Mean number of persons per bedroom was 2.8. Only 7.0% of the bedrooms had TV; 98.1% slept in silence. The data obtained support the need to weigh cultural factors influence on sleep.

Increased infant axillary temperatures in non-REM sleep during mother-infant bed-sharing

This study addressed the effect of mother-infant bed-sharing on infant body temperature and possible mediating mechanisms. Axillary temperatures were recorded for the entire night in 26 infants on both a bed-sharing night and a solitary sleeping night, accompanied by polysomnography and video-taping to allow assignment of sleep stages and behavioral analysis. All infants were approximately 3 months old, healthy, Latino and breast-feeding; 16 of the infants bed-shared since birth while the others routinely slept alone. Bed-sharing was associated with a significantly increased mean axillary temperature compared to solitary sleeping in both routine bed sharers and routine solitary sleepers. This increase was expressed only in non-REM sleep, with no differences during REM sleep or waking. The increase in temperature during bed-sharing may be related to an increased frequency of transient, movement-associated arousals during bed-sharing.

Infant mechanical suffocation deaths in the United States, 1980-1997

PURPOSE

To document specific patterns and products associated with mechanical suffocation among infants younger than 13 months of age for the period 1980 to 1997.

METHODOLOGY

A total 2178 case summaries from the US Consumer Product Safety Commission's Death Certificate File were reviewed. A computerized database was created for information about the infants, products, and patterns of suffocation. The relationships among products, patterns, and age groups were analyzed by chi2. Thirty-eight investigations conducted on a subset of cases involving cribs were reviewed for details on crib age, structural integrity, and compliance with the federal crib regulation. Mortality rates were calculated based on the US population younger than 1 year old.

RESULTS

The most frequent causes of suffocation were 1) wedging between a bed or mattress and a wall and 2) oronasal obstruction by plastic bag. Patterns of suffocation were significantly related to age group, but not to sex. Pattern-specific mortality rates comparing three time frames for the the 16-year period from 1980 to 1995 showed continued increases for overlain and oronasal obstruction; an increase followed by a plateau for wedging, a decrease for hanging, and no substantial change for entrapment with suspension.

CONCLUSIONS

Suffocation hazards presented by beds, bedding, pillows, and plastic bags continue to be underrecognized by parents and caregivers. Bed-sharing and use of adult beds for infants should be discouraged. Only complying cribs should be used and maintained properly to ensure structural integrity. Suffocation deaths involving plastics should be investigated to determine the specific material characteristics and use patterns to design more effective interventions than selective labeling.

Sleep habits in Native Brazilian Bororo children

Sleep behavior patterns in childhood are influenced by familial, cultural and environmental factors. In understanding sleep in Native Brazilian Bororo children, one should consider the influence of their culture on the child's sleep. This research analyzes sleep habits of Native Bororo children from the Meruri village, located in an Indian Reservation in the state of Mato Grosso. Fourty four children (24 M; 20 F) were evaluated; ages ranged from one month to 10 years, with a mean age of 4.9 years. Sleep characteristics were assessed by means of a standard questionnaire applied to the mothers. Cosleeping--sleeping together with family members--was a remarkable finding, in every child 0-2 year old and in 81.5% in the 2-10 years group. The second characteristic was sleeping with many people in the same room. There was an average of 5.1 people per room in the younger group and 3.9 people in the older group.

Sleep habits in native Brazilian Terena children in the state of Mato Grosso do Sul, Brazil

Sleep habits in childhood vary in function of physiological factors. Cultural traits also influence sleep habits. This research evaluates sleep habits of Native Brazilian Terena children. The Terena group here studied live in the central region of Mato Grosso do Sul, Brazil, on the plains; they are peaceful and dedicated mainly to agriculture. Two villages were studied, Tereré and Córrego do Meio, both in Reservations. Sleep characteristics of 67 children (40M;27F), 2 to 10 year olds, were evaluated in interviews with their mothers. The results evidenced that cosleeping, in the same bed with family members is the standard Terena pattern present in every evaluated child. The presence of two or more beds and a mean of five or more people in each bedroom was the typical finding. The authors propose that cosleeping and the presence of numerous family members reflect the high values attributed to family links in the Terena culture.

Side sleeping position and bed sharing in the sudden infant death syndrome

In the last decade there have been major reductions in the sudden infant death syndrome (SIDS) rate following prevention programmes in Australasia, Europe and North America, mainly due to changing infants from the prone sleeping position onto their sides or backs. This report reviews previous SIDS observational studies with data on side sleeping position and bed sharing. The relative risk for SIDS calculated from previous studies for side vs back sleeping position is 2.02 (95% CI = 1.68, 2.43). This result suggests that further substantial decreases in SIDS could be expected if infants were placed to sleep on their backs. With regard to bed sharing, the summary SIDS relative risk is 2.06 (1.70, 2.50) for infants of smoking mothers and 1.42 (1.12, 1.79) for infants of nonsmoking mothers. Public health policy should be directed against bed sharing by infants whose mothers smoke as they carry an increased risk of SIDS from bed sharing in addition to their already increased risk from maternal smoking. For infants of nonsmoking mothers, who have a low absolute risk of SIDS, the 40-50% increase in risk needs to be balanced against other perceived benefits from bed sharing, such as increased breastfeeding.