The Atlantic Divide: Contrasting U.K. and U.S. Recommendations on Cosleeping and Bed-Sharing

This Insights in Practice explores the current state of guidance regarding sudden infant death syndrome (SIDS) and cosleeping or bed-sharing in the United Kingdom and United States (cosleeping and bed-sharing have been used interchangeably to describe an infant and one or more parents/ adults/others sharing a sleep surface, with some variations as discussed below). The goal is to help lactation professionals and allied staff become aware of the larger contextual picture on this topic and to encourage reflection on how we educate new parents around infant sleep location. There is no doubt that the issue of babies sleeping with their parents has been a polarizing topic; previously, I have likened it to a tug of war between different theoretical and ideological perspectives, with health professionals and parents caught in the middle of an academic debate about contradictory evidence and appropriate advice. But, over the past 2 to 3 years, the nature and content of discussions on this topic have begun to shift, and agreements are emerging. As will be discussed later, the tug of war is no longer an appropriate metaphor to represent the clarifying picture of bed-sharing and cosleeping. The literature cited here includes examples of key (well-known) papers in the chronology of the debate about SIDS and sleep location as well as papers providing specific evidence supporting a point. The bed-sharing/cosleeping debate ignited in the 1990s during a period of intense research and public health activity around unexplained infant deaths that occurred during sleep and peaked during the 3rd month of life (SIDS). Epidemiologic studies conducted in the 1980s had identified that infant sleep position was strongly linked with SIDS (Gilbert, Salanti, Harden, & See, 2005), and high-profile risk-reduction campaigns in many countries informed parents to sleep babies on their backs. Why the supine sleep position was protective was unclear (and still is), but central apnea (involving sudden cessation of breathing) was a key hypothesis at the time. SIDS rates were high in many Western countries, and as well as sleeping prone, most babies slept in cribs in a separate room from their parents. Researchers exploring night-time infant care from an evolutionary perspective proposed that, as solitary sleeping was not the evolutionary norm for human infants, close mother– infant sleep proximity (cosleeping, initially defined as mother and baby sharing a bed) might reduce sudden and unexplainable infant deaths (SIDS) by promoting maternal– infant microarousals throughout the night and preventing central apneas (McKenna, 1986). They noted that infants undergo dramatic changes in their breathing control around 3 months of age, making them particularly vulnerable to unpredictable breathing cessation (McKenna & Mosko, 1990). Although a National Institutes of Health–funded study of breastfeeding cosleeping mothers and babies supported the hypothesis that sleep contact promoted regular night-time interaction and lighter stages of sleep, this study was not designed to assess SIDS outcomes (Mosko, Richard, & McKenna, 1997). As the cosleeping hypothesis gained traction, epidemiologists examining bed-sharing found that it was associated with more rather than fewer SIDS cases (Mitchell & Scragg, 1993). Initial epidemiologic data were fairly unsophisticated: definitions of “bed-sharing deaths” varied widely between studies, encompassing sofa-sharing, sleep-sharing with siblings or pets, and sleeping with a parent for some portion of the night but discovered dead in a crib (Côté, 2006). Control families’ reports of bed-sharing ranged from “usual behavior,” to sleep location on a particular night (or part thereof), to ever sharing a sleep surface. Data were not comparable between studies or even between cases and controls in the same study (Ball, Hooker, & Kelly, 1999). 713943 JHLXXX10.1177/0890334417713943Journal of Human LactationBall research-article2017