Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska

Effect of sleep position in term healthy newborns on sudden infant death syndrome and other infant outcomes: A systematic review

Background

Though recommended by numerous guidelines, adherence to supine sleep position during the first year of life is variable across the globe.

Methods

This systematic review of randomized trials and observational studies assessed the effect of the supine compared to non-supine (prone or side) sleep position on healthy newborns. Key outcomes were neonatal mortality, sudden infant death syndrome (SIDS), sudden unexpected death in infancy (SUDI), acute life-threatening event (ALTE), neurodevelopment, and positional plagiocephaly. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021). Two authors separately evaluated the risk of bias, extracted data, and synthesised effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence.

Results

We included 54 studies (43 observational studies and 11 intervention trials) involving 474 672 participants. A single study meeting the inclusion criteria suggested that the supine sleep position might reduce the risk of SUDI (0-1 year; OR = 0.39, 95% confidence interval (CI) = 0.23-0.65; 384 infants), compared to non-supine position. Supine sleep position might reduce the risk of SIDS (0-1 year; OR = 0.51, 95% CI = 0.42-0.61; 26 studies, 59332 infants) and unexplained SIDS/severe ALTE (neonatal period; OR = 0.16, 95% CI = 0.03-0.82; 1 study, 119 newborns), but the evidence was very uncertain. Supine sleep position probably increased the odds of being 0.5 standard deviation (SD) below mean on Gross Motor Scale at 6 months (OR = 1.67, 95% CI = 1.22-2.27; 1 study, 2097 participants), but might have little to no effect at 18 months of age (OR = 1.16, 95% CI = 0.96, 1.43; 1 study, 1919 participants). An increase in positional plagiocephaly at 2-7 months of age with supine sleep position is possible (OR = 2.77, 95% CI = 2.06-3.72; 6 studies, 1774 participants).

Conclusions

Low- to very low-certainty evidence suggests that supine sleep position may reduce the risk of SUDI (0-1 year) and SIDS (0-1 year). Limited evidence suggests that supine sleeping probably delays short-term ‘gross motor’ development at 6 months, but the effect on long-term neurodevelopment at 18 months may be negligible.

Reasons mothers bedshare: A review of its effects on infant behavior and development

Bedsharing is controversial for nighttime caregiving in the U.S. today, as in most of the West. However, from the standpoint of evolutionary pediatrics, anthropology, and cultural psychology, bedsharing is not controversial at all, representing the context for human infant evolution and conferring a host of physiological benefits to the infant as well as the mother. In an effort to understand the rise in Western bedsharing in recent decades (and following Ball, 2002; McKenna & Volpe, 2007), Salm Ward (2015) systematically reviewed the literature on mother-infant bedsharing and identified ten reasons why mothers choose to bedshare: (1) breastfeeding, (2) comforting for mother or infant, (3) better/more sleep for infant or parent, (4) monitoring, (5) bonding/ attachment, (6) environmental reasons, (7) crying, (8) cultural or familial traditions, (9) disagree with danger, and (10) maternal instinct. The current paper offers the "review behind the review," highlighting the scientific evidence behind the reasons mothers give for their decision to bedshare, focusing on how mothers' decisions about infant sleep location influence infant behavior and development.

Trend of unintentional suffocation death for infants under 1 year of age from 2009 to 2018 in Hunan, China: a cross-sectional study

OBJECTIVE

Few studies have addressed the unintentional suffocation of infants in China. This study is to assess the mortality rate of unintentional suffocation among infants and the differences across age groups, gender, rural versus urban locations and related healthcare services.

DESIGN

A cross-sectional study on unintentional suffocation death of infants under 1 year of age in Hunan Province from 2009 to 2018.

SETTING

Hunan Province, with a population of 74 million, has an area of 210 000 square kilometres and 123 counties/districts.

PARTICIPANTS

The total data of 4109 unintentional suffocation deaths of infants in Hunan Province from 2009 to 2018 was collected, including 2331 boys, 1766 girls, 12 infants of unknown gender, 2906 rural children and 1203 urban children.

MAIN OUTCOME MEASURE

The unintentional suffocation mortality rate of infants is defined as the number of unintentional suffocation deaths of children under 1 year of age per 100 000 live births in the same year.

RESULTS

The infant mortality rate showed a downward trend from 2009 to 2018. Infant unintentional suffocation death decreased first and then fluctuated. The proportion of unintentional suffocation death to infant death showed an upward trend in fluctuation. Boys and rural children had higher mortality rates than those of girls and urban children. A total of 43.5% of the deaths occurred in winter. Forty-eight per cent of the unintentional suffocations were infants between 1 and 4 months of age. A total of 46.4% of the deaths occurred at home, and 71.6% were not treated; approximately 81.8% of the untreated cases were mainly due to a lack of time to get to the hospital. A total of 65.2% of the deaths were diagnosed postmortem.

CONCLUSION

The mortality rate of unintentional suffocation among infants in Hunan Province should attract the attention of the population, and measures should be taken according to epidemiological investigations.

A Nursing Perspective on Infant Bed-Sharing Using Multidisciplinary Theory Integration

The American Academy of Pediatrics recommends against bed-sharing between infants and caregivers due to an association with suffocation. Caregivers continue to share a bed with their infant despite these recommendations for a multitude of reasons. A close examination of the bed-sharing literature reveals that the debate is fundamentally about theoretical differences. The major theories used to frame this problem include the triple risk model of bed-sharing and evolutionary theories. Nurses are masters of multidisciplinary collaboration and are well positioned to unify the triple risk and evolutionary views of infant bed-sharing to guide future innovations in health care practice and research.

Infant Suffocation Incidents Related to Co-Sleeping or Breastfeeding in the Side-Lying Position in Japan

Co-sleeping and breastfeeding in the side-lying position have recently been pointed out as risk factors for suffocation in sleeping infants; however, there is no actual report on an "incident." "Incident" is defined as a tense or sobering experience without a consequential fatal suffocation accident. It is important to understand infant suffocation incidents to prevent accidents during co-sleeping and breastfeeding in the side-lying position. We investigated factors and frequency of infant suffocation incidents associated with co-sleeping and breastfeeding in the side-lying position using a self-administered questionnaire survey of 895 mothers during their infant's 1-, 4-, or 10-month health checkups. Co-sleeping and breastfeeding in the side-lying position were practiced by 28.3% and 56.0% of mothers, respectively; thus, 84.3% of the mothers surveyed were practicing either co-sleeping or breastfeeding in the side-lying position. Of those who received guidance from a medical professional, 36.1% practiced only co-sleeping while 60.1% practiced only side-lying breastfeeding. In the co-sleeping group, 10.6% had faced infant suffocation incidents, while 13.2% in the breastfeeding in the side-lying position group had faced similar incidents. Regarding factors associated with suffocation incidents while co-sleeping, the frequency of occurrence was significantly more in mothers of 1-month and 4-month-old infants compared with those of 10-month-old infants. Of mothers who faced suffocation incidents while breastfeeding in the side-lying position, 45% also had faced similar incidents while co-sleeping. These results demonstrate the importance of thoroughly educating mothers about the risks associated with co-sleeping and breastfeeding in the side-lying position for preventing infant suffocation.

Babies in boxes and the missing links on safe sleep: Human evolution and cultural revolution

Concerns about bedsharing as a risk for sudden infant death syndrome and other forms of sleep-associated infant death have gained prominence as a public health issue. Cardboard "baby boxes" are increasingly promoted to prevent infant death through separate sleep, despite no proof of efficacy. However, baby boxes disrupt "breastsleeping" (breastfeeding with co-sleeping) and may undermine breastfeeding. Recommendations enforcing separate sleep are based on 20th century Euro-American social norms for solitary infant sleep and scheduled feedings via bottles of cow's milk-based formula, in contrast to breastsleeping, an evolutionary adaptation facilitating the survival of mammalian infants for millennia. Interventions that aim to prevent bedsharing, such as the cardboard baby box, fail to consider the implications of evolutionary biology or of ethnocentrism in sleep guidance. Moreover, the focus on bedsharing neglects more potent risks such as smoking, drugs, alcohol, formula feeding, and poverty. Distribution of baby boxes may divert resources and attention away from addressing these other risk factors and lead to a false sense of security wherein we overlook that sudden unexplained infant deaths also occur in solitary sleep environments. Recognizing breastsleeping as the evolutionary and cross-cultural norm entails re-evaluating our research and policy priorities, such as providing greater structural support for families, supporting breastfeeding and safe co-sleeping, investigating ways to safely minimize separation for formula-fed infants, and mitigating the potential harms of mother-infant separation when breastsleeping is disrupted. Resources would be better spent addressing such questions rather than on a feel-good solution such as the baby box.

Qualitative Analysis of Infant Safe Sleep Public Campaign Messaging

The 1994 Back to Sleep public education campaign resulted in dramatic reductions in sleep-related infant deaths, but comparable progress in recent years has been elusive. We conducted qualitative analyses of recent safe sleep campaigns from 13 U.S. cities. Goals were to (a) determine whether the campaigns reflect the full range of American Academy of Pediatrics (AAP) 2011 safe sleep recommendations, (b) describe tone and framing of the messages (e.g., use of fear appeals), (c) describe targeting/tailoring of messages to priority populations, and (d) ascertain whether the campaigns have been evaluated for reach and/or effectiveness. Methods included computer-assisted analyses of campaign materials and key informant interviews. All campaigns included "ABC" (Alone, Back, Crib) messaging; many ignored other AAP recommendations such as breastfeeding, room-sharing, immunizations, and avoiding smoke exposure. Campaigns frequently targeted priority populations such as African Americans. Fear appeals were used in three quarters of the campaigns, and 60% of the fear-based campaigns used guilt/blame messaging. We did not find published evaluation data for any of the campaigns. More attention is needed in public education campaigns to the full range of AAP recommendations, and evaluations are needed to determine the impact of these interventions on knowledge, behavior, and health outcomes.

Sleep-Related Infant Deaths in Victoria: A Retrospective Case Series Study

BACKGROUND

There is general agreement that in some circumstances, sharing a sleep surface of any kind with an infant increases the risk of sudden unexpected death in infancy. There is a paucity of research conducted in Australia examining this issue. This study examines the frequency and distribution of sleep-related infant deaths in a defined population, and reports the proportion that occurred in the context of bed-sharing.

METHODS

A retrospective population-based case series study was conducted of infants (≤365 days) who died in a sleeping context during the period 1 January 2008 to 31 December 2010 in the state of Victoria, Australia. Information about the infant, caregiver, sleeping environment and bed-sharing was collected from a review of the coroner's death investigation record.

RESULTS

During the 3-year study period, 72 infant deaths occurred in a sleeping context. Of these, 33 (45.8 %) occurred in the context of bed-sharing: n = 7 in 2008; n = 11 in 2009; and n = 15 in 2010. Further analysis of the 33 deaths occurring in the context of bed-sharing showed that in this group, bed-sharing was largely intentional, habitual and most often involved the mother as one of the parties.

CONCLUSIONS

Given the case series nature of the study design, a causal relationship between bed-sharing and infant death could not be inferred. However the fact that nearly half of all sleep-related deaths occurred in the context of bed-sharing, provides strong support for the need to undertake definitive analytic studies in Australia so that evidence-based advice can be provided to families regarding the safety of bed-sharing practices.

Development of the National Healthy Sleep Awareness Project Sleep Health Surveillance Questions

OBJECTIVES

For the first time ever, as emphasized by inclusion in the Healthy People 2020 goals, sleep health is an emphasis of national health aims. The National Healthy Sleep Awareness Project (NHSAP) was tasked to propose questions for inclusion in the next Behavioral Risk Factor Surveillance System (BRFSS), a survey that includes a number of questions that target behaviors thought to impact health, as a means to measure community sleep health. The total number of questions could not exceed five, and had to include an assessment of the risk for obstructive sleep apnea (OSA).

METHODS

An appointed workgroup met via teleconference and face-to-face venues to develop an inventory of published survey questions being used to identify sleep health, to develop a framework on which to analyze the strengths and weaknesses of current survey questions concerning sleep, and to develop recommendations for sleep health and disease surveillance questions going forward.

RESULTS

The recommendation was to focus on certain existing BRFSS questions pertaining to sleep duration, quality, satisfaction, daytime alertness, and to add to these other BRFSS existing questions to make a modified STOP-BANG questionnaire (minus the N for neck circumference) to assess for risk of OSA.

CONCLUSIONS

Sleep health is an important dimension of health that has previously received less attention in national health surveys. We believe that 5 questions recommended for the upcoming BRFSS question banks will assist as important measures of sleep health, and may help to evaluate the effectiveness of interventions to improve sleep health in our nation.

Speaking out on safe sleep: evidence-based infant sleep recommendations

The American Academy of Pediatrics (AAP) issued recommendations in 2005 and 2011 to reduce sleep-related infant death, which advise against all bedsharing for sleep. These recommendations overemphasize the risks of bedsharing, and this overemphasis has serious unintended consequences. It may result in increased deaths on sofas as tired parents try to avoid feeding their infants in bed. Current evidence shows that other risks are far more potent, such as smoking, shared sleep on sofas, sleeping next to impaired caregivers, and formula feeding. The emphasis on separate sleep is diverting resources away from addressing these critical risk factors. Recommendations to avoid bedsharing may also interfere with breastfeeding. We examine both the evidence behind the AAP recommendations and the evidence omitted from those recommendations. We conclude that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death. No sleep environment is completely safe. Public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants, especially if parents are smokers or under the influence of alcohol or drugs. All messaging must be crafted and reevaluated to avoid unintended negative consequences, including impact on breastfeeding rates, or falling asleep in more dangerous situations than parental beds. We must realign our resources to focus on the greater risk factors, and that may include greater investment in smoking cessation and doing away with aggressive formula marketing. This includes eliminating conflicts of interest between formula marketing companies and organizations dedicated to the health of children.

Application of a Socio-Ecological Model to Mother–Infant Bed-Sharing

Mother–infant bed-sharing has been associated with an increased risk of sleep-related infant deaths, and thus, health messaging has aimed to discourage this behavior. Despite this messaging, bed-sharing remains a common practice in the United States, especially among minority families. Moreover, rates of accidental suffocation and strangulation in bed (often related to bed-sharing) are on the rise, with Black infants at two to three times greater risk than Whites. Multiple studies have identified risk factors for bed-sharing, but a gap remains between findings and translation into interventions. The socio-ecological model (SEM) has been suggested as a way to study and design interventions addressing complex public health issues. This article reconceptualizes the literature on mother–infant bed-sharing using the SEM. PubMed, POPLINE, ERIC, and Psych Info were searched for articles that (a) included bed-sharing as the outcome variable, (b) were published between 2000 and 2013, (c) were conducted in the United States, and (d) included quantitative comparison of more than one factor. The following data were extracted: sample characteristics, bed-sharing definition, methods, factors examined, key findings, and conclusions. Data were summarized into five SEM levels—infant, maternal, family and household, and community and society, nested within the historical context of race. Sixteen studies met inclusion criteria. Significant factors associated with bed-sharing were present within each SEM level of influence. Educational interventions may increase efficacy by attending to multiple levels of the SEM, especially when implementing such interventions within minority subpopulations. Using a harm reduction approach to reducing the risk around bed-sharing may be one way to account for the multiple influences on bed-sharing. The science and practice of minimizing mother–infant bed-sharing may be advanced through use of the SEM.

The Black and White of infant back sleeping and infant bed sharing in Florida, 2004-2005

Not using the infant back sleep position is an established risk factor for sudden unexpected infant death (SUID). Infant bed sharing may also increase SUID risk, particularly under certain circumstances. Both of these infant sleeping behaviors are disproportionately higher among Black mothers. We explored the relationship between not using the infant back sleeping and infant bed sharing, developed separate risk factor profiles for these behaviors, and identified maternal characteristics contributing to racial differences in their practice. Merged 2004-2005 birth certificate and Pregnancy Risk Assessment Monitoring System data for 2,791 non-Hispanic Black and White Florida women were evaluated using univariable and multivariable analyses to develop risk factor profiles for infrequent back sleeping and frequent bed sharing. Cross-product interaction terms were introduced to identify factors contributing to racial differences. Infrequent back sleeping and frequent bed sharing were reported by two-thirds of Black women and one-third of White women. There was no association between the infant sleeping behaviors when adjusted for race (adjusted odds ratio [aOR], 1.04; 95% CI, 0.83-1.31). The infant sleeping behaviors shared no common independent maternal characteristics. Father acknowledgement on the birth certificate was a strong contributor to racial differences in infrequent back sleeping while breastfeeding, trimester of entry to prenatal care, and maternal depression revealed notable racial differences for bed sharing. Behavior-specific and race-specific public health messages may be an important public health strategy for reducing risky infant sleeping behaviors and decreasing SUIDs.

Bed- and sofa-sharing practices in a UK biethnic population

OBJECTIVE

To describe the prevalence and associations of bed- and sofa-sharing in a biethnic UK birth cohort.

METHODS

We surveyed 3082 participants in the Born in Bradford birth cohort study by using a telephone interview when infants were aged 2 to 4 months. We asked families about sleep surface sharing behaviors, and other sudden unexpected death in infancy (SUDI)-related behaviors.

RESULTS

There were 15.5% of families that had ever bed-shared, 7.2% of families regularly bed-shared, and 9.4% of families had ever sofa-shared with their infants; 1.4% reported both. Regular bed-sharers were more commonly Pakistani (adjusted odds ratio [aOR] = 3.02, 95% confidence interval [CI] 1.96-4.66), had further or higher educational qualifications (aOR = 1.62, 95% CI 1.03-2.57), or breastfed for at least 8 weeks (aOR = 3.06, 95% CI 2.00-4.66). The association between breastfeeding and bed-sharing was greater among white British than Pakistani families. Sofa-sharing occurred in association with smoking (aOR = 1.79, 95% CI 1.14-2.80) and breastfeeding for more than 8 weeks (aOR = 1.76, 95% CI 1.19-2.58), and was less likely in Pakistani families (aOR = 0.21, 95% CI 0.14-0.31), or single-parent families (aOR = 0.50, 95% CI 0.29-0.87).

CONCLUSIONS

The data confirm that bed-sharing and sofa-sharing are distinct practices, which should not be combined in studies of unexpected infant deaths as a single exposure. The determinants of sleep-surface sharing differ between the UK Pakistani and UK majority communities, and from those of US minority communities. Caution is needed in generalizing SUDI/SIDS risk factors across populations with differing risk factor profiles, and care should be taken in adopting SUDI/SIDS reduction guidelines from other contexts.

Relationship between bed sharing and breastfeeding: longitudinal, population-based analysis

OBJECTIVES

This is an investigation into the longitudinal patterns of bed sharing, the characteristics associated with those patterns, and the relationship with breastfeeding.

METHODS

The study used prospective, population-based data from the United Kingdom to investigate nocturnal bed sharing at 5 time points from birth to 4 years of age. Of 14 062 live births, 7447 (53%) had data available for all time points.

RESULTS

Latent class analysis identified 4 mutually exclusive groups, broadly described as nonsharers (66%), early bed sharers (only in infancy) (13%), late bed sharers (after the first year) (15%), and constant bed sharers (throughout the 4 years) (6%). The boy/girl ratio and the proportion of families of nonwhite ethnicity were slightly higher in all 3 bed-sharing groups, compared with the non-bed-sharing group. Higher maternal educational achievement and higher social class were positively associated with early bed sharing, negatively associated with late bed sharing, and not associated with constant bed sharing. The 3 bed-sharing patterns were related significantly to breastfeeding at 12 months (P < .001), whether the families shared beds late (odds ratio: 1.72 [95% confidence interval: 1.36-2.18]), early (odds ratio: 2.36 [95% confidence interval: 1.87-2.97]), or for the whole period (odds ratio: 5.29 [95% confidence interval: 4.05-6.91]). The prevalence of breastfeeding was significantly higher among the groups that shared beds constantly or early for each of the first 15 months after birth.

CONCLUSIONS

Advice on whether bed sharing should be discouraged needs to take into account the important relationship with breastfeeding.