BREASTFEEDING MEDICINE
Volume 18, Number 3, 2023
ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2023.29236.abm

ABM Protocol

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ABM Clinical Protocol #37:
Physiological Infant Care—Managing Nighttime
Breastfeeding in Young Infants
Deena Zimmerman,1 Melissa Bartick,2,3 Lori Feldman-Winter,4 and Helen L. Ball5;and the Academy of Breastfeeding Medicine

Abstract

A central goal of the Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols for
managing common medical problems that may impact breastfeeding success. These protocols serve only as
guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course oftreatment or serve as standards of medical care. Variations in treatment may be appropriate according to theneeds of an individual patient. The ABM empowers health professionals to provide safe, inclusive, patientcentered, and evidence-based care. Pregnant and lactating people identify with a broad spectrum of genders,pronouns, and terms for feeding and parenting. There are two reasons ABM’s use of gender-inclusive language
may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving
across languages, cultures, and countries. Second, foundational research has not adequately described theexperiences of gender-diverse individuals. Therefore, ABM advocates for, and will strive to use language that is
as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position
Statements on Infant Feeding and Lactation-Related Language and Gender (https://doi.org/10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (https://doi.org/10.1089/bfm.2022.29216.abm).
Keywords: breastfeeding, infant care, newborn, infant, sleep deprivation, sudden infant death

IntroductionH

aving a newborn can be overwhelming, even forexperienced parents. Infant feeding and getting sufficient sleep are among parents’ biggest concerns. Young infants require frequent feedings day and night, particularly
those who are breastfeeding. This can be a challenge toparents who are balancing other responsibilities such as workoutside the home, caring for older children, and daily
household responsibilities. The goal of this protocol is toaddress managing these challenges in the context of normal
physiology for breastfeeding dyads.

Academy of Breastfeeding Medicine (ABM) Protocol #6(Bedsharing and Breastfeeding),1 serves as an important
adjunct to this protocol.
Key Information
Normal maternal–infant physiology
Normal infant feeding patterns. A newborn will breastfeed *8 to 12 times per 24 hours but not necessarily at
regular intervals. Newborns need to breastfeed according totheir feeding cues. As stated in the rationale to step 8 of therevised Baby-Friendly Hospital Initiative, ‘‘Breastfeeding

1

Maternal-Child and Adolescent Division, Public Health Service, Israel Ministry of Health, Jerusalem, Israel.
Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, USA.
3
Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
4
Department of Pediatrics, Cooper Medical School of Rowan University, Camden, New Jersey, USA.
5
Durham Infancy and Sleep Centre, Department of Anthropology, Durham University, Durham, United Kingdom.
2

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involves recognizing and responding to the infant’s display ofhunger and feeding cues and readiness to feed, as part of anurturing relationship between the mother and infant.’’
Responsive feeding (also called on-demand or baby-led
feeding) puts no restrictions on the frequency or length of theinfant’s feeds, and mothers are advised to breastfeed whenever the infant is hungry or as often as the infant wants,
acknowledging that healthy infants self-regulate intake bycombining nutritive with non-nutritive suckling.2 Feedingaccording to infant cues helps assure that an infant receives
all the needed daily nutrition,3 as long as a minimum of eight
feedings per 24 hours is met.
Once complementary foods are added at 6 months, the infant
may be able to feed less often at night. However, when mothers
work outside the home and express their milk while away fromtheir infants, some dyads may engage in reverse-cycle feeding,
directly breastfeeding more often during the night to make up forthe mother’s daytime absence. This direct stimulation by the
infant at the breast helps maintain milk production. Intentionallylimiting nighttime feeding is associated with early cessation of
exclusive breastfeeding.4 Expressing milk is less efficient thandirect breastfeeding, even with the most efficient breast pumps.5
Direct breastfeeding more often at night may thus help withmaintaining milk production after returning to work.
Normal infant sleep patterns. Newborns are born without
a functional circadian clock.6 Melatonin in breast milk issecreted and passed on to the infant in a circadian manner,helping to establish the infant’s circadian rhythm.7 Being
exposed to usual daytime activities, and their differentiationfrom nighttime activities, helps set an infant’s circadian clock
and lengthen their nighttime sleep periods. This includes
daytime naps without artificially darkening the room or significantly reducing ambient noise.
Continuous proximity and skin-to-skin contact with themother or other adult help the infant gradually transition to
extrauterine life. Infants rely on proximity and skin-to-skincontact with their mothers to regulate their breathing, temperature, and heart rate in the early weeks and months oflife.8–10 Mother–infant physical contact among breastfeeding
dyads (bedsharing and baby-wearing) predicts maternal responsiveness to infant hunger cues, whereas proximity without physical contact does not.11 Responsive feeding, in turn, isassociated with longer duration of exclusive breastfeeding.11
Nighttime separation from the mother in infants as old as 10months can cause infant distress and elevated cortisol levels,
even if the infant does not appear outwardly distressed.12 Furthermore, although nighttime separation during the first 4 months
may be associated with longer periods of sleep consolidation in
the infant13 and decreased night-time awakenings,14 this may not
be physiological or safe, and partially explain why sleeping inproximity to the mother is associated with a decreased risk of
sudden infant death syndrome (SIDS).15
Differences in sleep patterns may vary according torace/ethnicity as well as maternal education and householdincome. Some investigators have examined sleep patterns by
race/ethnicity and other sociodemographic variables in an
attempt to understand disparities in SIDS rates among certain
U.S. groups. Results indicated that lower income and lesseducation, not race/ethnicity, were associated with less sleep
duration among dyads.16 These factors may be markers forstress, which may adversely affect sleep physiology.

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After 12 to 16 weeks, the infant will spend more timeawake, as the suprachiasmatic nucleus, based on externalcues, begins to establish a circadian rhythm.17 The infant will
be able to go longer stretches between feeds and will be able
to feel comfortable outside immediate physical contact with
their mother. However, their longest sleep periods may notmarkedly lengthen between 3 and 12 months, whether they
are room sharing or sleeping solitary.18 Mothers may makeup for their own nighttime sleep loss with daytime naps.19
However, their naps may not provide the same restorativevalue as nighttime sleep.20
Infants also benefit from being carried even when not
feeding. A randomized controlled trial in a Western highincome setting showed that increased carrying of infants inarms or in a baby carrier with body contact (baby-wearing) was
associated with a 43% reduction in fussing and crying at 6
weeks of age.21 Safe baby-wearing (see information)22 can also
allow a mother to participate in other tasks. Infants who spend
much of their day being carried may benefit from supervised‘‘tummy time’’ to help achieve developmental motor goals.23
Challenges to physiological infant care
Expectations of sleeping through the night. In Westernhigh-income countries, there is an expectation that a ‘‘good
baby’’ should be able to sleep long stretches through the nightfrom a very young age.7 The recommendation of exclusive
breastfeeding for the first 6 months of life24 is often the social
expectation, but is incompatible with the ‘‘good baby’’
expectation.
The scientific data show that expectations of prolonged
infant sleep periods are unrealistic. Infant sleep measured by
actigraphy (movement sensors) is similar from ages 4 to 16
weeks, regardless of the infant feeding method or location
with respect to mother. However, Western mothers who exclusively formula feed perceive that their infants sleep longer, which reflects and reinforces the myth that it is ‘‘normal’’for infants to sleep soundly for long periods.25 Parents in
Western societies may experience distress and feel unprepared when their infants do not fit the expectation of readily
falling asleep alone and staying asleep for long stretches froman early age.26
The mismatch between Western cultural family sleep expectations and the biological realities of human infants undermines parental resilience and compromises family wellbeing.7 In contrast to Western mothers, one study showed
Japanese mothers do not perceive their sleep to be disturbed,
despite the objective measures of infant-related sleep disruption being similar to those found in the U.S. studies of
postpartum women who reported sleep disturbance.27
Studies have documented that infant’s sleep patterns, although fragmented throughout the night, do not correlate withmaternal sleep duration after 6 weeks postpartum.28 Breastfeeding infants sleep as well as or better than their formula
feeding counterparts.19 A systematic review and metaanalysis demonstrated that breastfeeding may be associatedwith a longer nighttime sleep postpartum and that bedsharing
was associated with longer sleep duration in breastfeeding
mothers, compared with non-breastfeeding mothers.29
Expectations around solitary sleep. In Western highincome countries, there is an expectation that solitary infantABM PROTOCOL

sleep is standard and desirable. Bedsharing has been stigmatized and considered as uniformly unsafe, even inbreastfeeding dyads without risk factors for sudden infant
death. Parents in most Western countries have been advised
against bedsharing since about 2004–2005,30 and strongly
advised against any bedsharing since *2010, and many
Western countries continue to advise against bedsharing.
Other authorities began removing this recommendation after
about 2014–2015.31,32 For example, in 2014 the U.K.’s National Institute for Health and Care Excellence advised that
there was insufficient research evidence to unambiguously
state cosleeping causes SIDS.
In 2016, PrevInfad in Spain gave a Level 1 recommendationthat there is insufficient evidence that bedsharing is associatedwith an increased risk of SIDS in breastfeeding infants when
there are no other risk factors.33 In 2019, the United Kingdom
removed routine advice against bedsharing, regardless of
feeding method.34–36 Australia adopted a risk minimization
strategy in 2018, which acknowledges that many parents
bedshare37 and some Canadian regional health authorities
became more accepting of bedsharing after *2017.38,39
The advice against all bedsharing is still very influential in
the United States and elsewhere, and continues to be the stanceof the American Academy of Pediatrics.40 A famous 2011 U.S.
advertising campaign, often cited, replaced a bedsharing mother with a meat cleaver. Mothers who bedshare can be accused of child abuse or neglect in some U.S. jurisdictions.41 In
other words, the normative infant sleeping and feeding patternis often viewed as aberrant, undesirable, or pathological.6,7
Scientific data show bedsharing to be associated withprolonged duration of any and exclusive breastfeeding.42–44
Sleep location is vital to feeding frequency.7 A growing bodyof anthropological research provides evidence that proximate
mother–infant sleep combined with side-lying breastfeeding(‘‘breastsleeping’’)45 constitutes the human evolutionary
norm.7 Bedsharing is associated with improved quality ofchild attachment and comforting for mother and infant.46
Bedsharing is common among U.S. infants47 and is common
among breastfeeding Turkish infants.48
Aspects of bedsharing may be protective against sleep-related
infant death. Proximate mother–infant sleep allows the motherto be immediately responsive to the infant, as demonstrated inphysiological studies.12,49 Mothers and infants are both morearousable,49,50 and the mother forms a protective circle aroundthe infant with her arms and legs, as her arm blocks the pillow
from the infant (known as the C-position or ‘‘cuddle-curl’’51).
The infant’s head is alongside the mother’s breast, and after
feeding the infant rolls onto their back, as bedsharing breastfeeding infants would not naturally sleep prone.52
By contrast, videographic evidence shows that mothers
who bottle feed their infants may exhibit unsafe practices
such as placing their infants to sleep on pillows.53 Furthermore, because bedsharing among breastfeeding dyads is socommon, it can be difficult if not impossible to separate out
the possible protective effects of bedsharing from the protective effects of breastfeeding. In other words, bedsharing
confounds the protective effect of breastfeeding on SIDS, andthus could be responsible for some of the decreased risk ofdeath associated with breastfeeding, when hazardous risks
are absent.54
Direct breastfeeding at night has important physiological
functions. In addition to the role of melatonin, breastfed in-161

fants who regularly bedshare feed more frequently than those
who sleep solitary.55 More frequent feeding at night may help
maintain milk production and is important for lactational
amenorrhea.56 Infants’ sleeping through the night is associated with a much lower rate of breastfeeding.57
Bedsharing affects maternal and infant sleep. Bedsharing
breastfeeding mothers wake frequently to feed, are awake
for shorter periods, and fall asleep more rapidly thanbreastfeeding mothers who do not bedshare.49 In a laboratory study of breastfeeding mothers, 94% of those whoroutinely bedshared reported they had obtained ‘‘enough’’sleep after bedsharing, compared with 80% of routinely
solitary sleeping mothers who reported enough sleep after
solitary sleeping.49
Mothers who routinely slept solitary also rated their sleep
quality as lower than bedsharing mothers.55 Bedsharing also
promotes infant arousals,50 which may be protective against
SIDS. Breastfeeding mothers sleep *40–45 minutes morethan formula feeding mothers19 and fathers of breastfed infants sleep longer than fathers of formula-fed infant infants.58
In societies that follow this physiological norm, a typicalnighttime behavior may consist of mothers and infants
sleeping together, breastfeeding frequently, often with themother not fully awake, and in the morning, the mothercannot say how often she breastfed.7,59 Infants and mothers
immediately return to sleep after feedings. Note that infants
fed this way are not burped after feeding; burping is rarely
necessary in infants fed directly at the breast because theygenerally do not swallow air during feeding. Note also that
infants are not awoken for diaper changes after every bowel
movement at night. Research suggests that breastfeeding is
associated with a lower risk of diaper dermatitis60,61 although
not in all studies.62 Application of a barrier cream to theinfant’s diaper area helps prevent diaper dermatitis.63
ABM Protocol #6 discusses the evidence to date that
bedsharing does not cause SIDS in the absence of hazardous
circumstances, despite its association with SIDS,1,64 consistent with other national guidelines.34 A well-done case–control study found bedsharing in the absence of hazards tobe protective in infants older than 3 months.64 ABM advises arisk-minimization approach to bedsharing and breastfeeding.1 Hazardous circumstances include, in order of importance: sofa sharing, sleeping with a parent who is impaired byalcohol or drugs, sleeping next to a smoker, sleeping in theprone position, never having initiated (direct) breastfeeding,sleeping in a chair with an adult, sleeping on soft bedding, or
sleeping with an infant who is preterm or low birthweight.
Note that most of these circumstances are amenable toparental control. However, in some cases, bedsharing may beunplanned, in which case it is much more hazardous thanwhen it is planned.65 If hazardous circumstances exist, alternatives such as a sidecar may be an option for somefamilies.1 The risk of bedsharing is unknown in dyads who
are fed by exclusive pumping, as infant positioning in bed fora breastfeeding dyad is uniquely related to the anatomical
demands required for direct feeding and the mother’s arms
and legs form a safe environment for the infant.1
Concerns that waking to breastfeed may contribute tomaternal depression. It has been hypothesized that dis-

rupted sleep may contribute to the development and extent of
postpartum depression symptoms.66 However, it is not clear

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whether postpartum sleep problems and mood disorders canbe attributed to infant sleep and feeding, as they often existed
in pregnancy. In addition, maternal sleep problems may becaused by anxiety and depression. Research showed that although there are significant correlations among maternal
sleep and wake disturbance, fatigue, and depression at 32
weeks postpartum, they are not related to infant sleep patterns
among Western mothers.67 Poor sleep maintenance, as
measured by wrist actigraphy, is correlated with maternal
depression, rather than maternal sleep duration.66
Poor sleep quality is also associated with worsening
postpartum depression and anxiety in Western mothers.68
Subjective perception of sleep, rather than its objective
quality, is associated with immediate and later postpartum
mood disturbances.20,66 In a longitudinal study of Western
mothers, pre-existing poor sleep quality, depression, andeating disorders during pregnancy were associated withworse breastfeeding outcomes, leading the authors to conclude that pre-existing sleep and mood disorders are the risk
factors for poor breastfeeding outcomes and postpartum sleep
disruption, and not that poor breastfeeding causes sleep disruption and postpartum mood disorders.69
Increased maternal depression and anxiety scores are also
linked to decreased maternal sleep efficiency. In other words,
maternal depression and anxiety are not related to the lengthof the infant’s self-regulated sleep periods, but rather toproblems with maternal sleep efficiency, or difficulty of themother initiating or falling back to sleep.70 Sleep efficiency isrelated to anxiety and increased sympathetic tone, not to thenumber of times a mother wakes to feed.70
Nonetheless, one study in Western mothers showed increased infant feeding, and more disturbed infant sleep wascorrelated with increased maternal depression.28 A study inJapanese mothers suggested that breastfeeding frequency,subjective fatigue, and decreased objective total sleep time in
the first days postpartum may be associated with higherscores on depression scales.71 It is notable that a comprehensive review and meta-analysis found a reduced risk of
postpartum depression associated with breastfeeding.72
Nonphysiological coping strategies

Variations from the normal physiology of proximate
mother–infant sleep while breastfeeding have the potential toundermine maternal well-being. Breastfeeding mothers may
have different strategies to maximize their sleep and wellbeing while avoiding bedsharing. These strategies may include
nocturnal pumping with bottle feeding, sleep training, formula
feeding or early introduction of solids, and use of infant
tracking apps, each of which has its own potential drawbacks.
Often these strategies involve turning on lights, which markedly disrupt circadian rhythms73 of the whole family.
Night pumping. Nighttime pumping while feeding an
infant a bottle of expressed milk would be expected tomarkedly disrupt maternal sleep. In addition, feeding milk
pumped from a different time of day would not provide theappropriate level of melatonin. Circadian rhythms are not
only disrupted by turning on lights, but by sitting up andengaging in any active activity.74
After feeding, a bottle-fed infant may require burping. If
the infant is not sleeping next to their parent, further sleep

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disruption to parents and infant may occur, as the infant may
not fall asleep readily while alone, and may require time forcalming and soothing. Exclusively pumping is also associated with shorter breast milk feeding duration and earlier
introduction of formula compared with feeding at the breast
with or without pumping.75
Sleep training. A number of techniques are designed tocondition infants and toddlers to sleep for longer periods atnight.76 They are based on reducing the infant’s expectation of a
specific behavior associated with sleep onset and conditioning
infants to ‘‘soothe themselves’’ back to sleep, alone, without
adult intervention, when they have normal sleep cycle awakening.76,77 Training young infants to sleep alone by failing to
respond to their crying in a distant crib causes significant infant
stress, as indicated by elevated infant cortisol levels, which
persist on the nights when the infant is no longer crying.12
Parents often experience distress at not responding to their infant’s cries,78,79 and often find sleep training is not effective.79
Objective measures of infant sleep outcomes do not findthat these methods ‘‘improve’’ the sleep of the infants who
undergo this training. Infants cease to signal distress to theirparents, but they do not cease to wake or remain awake, sothey are not actually ‘‘soothing themselves back tosleep.’’80,81 Sleep training in infants younger than 6 months ofage can impact breastfeeding success due to separation frommother and reduced nighttime feedings.80 In addition, having
the infant sleep in a separate room as part of sleep training
strategy could be associated with an increased risk of SIDS.70
However, some studies show sleep training conductedunder research conditions can be effective when the outcomes relate to maternal self-reported sleep outcomes, maternal reports of infant night waking, or maternal mental
health.82 One randomized control trial of 14 infants76 showed
no connection between graduated sleep interventions andemotional or behavioral problems 12 months later, but theseresults are too small to be generalizable.
Nonbreast milk feeding. In the pursuit of additional infant sleep, some mothers add or switch to formula to attempt
to get more sleep.83,84 However, wrist actigraphy shows thatparents of infants who were breastfed in the evening slept anaverage of 40–45 minutes more than parents who gave formula.19 Wrist actigraphy also showed that parents of infants
giving formula reported more sleep disturbance than parentsof exclusively breastfed infants.19 Data regarding early introduction of solids are mixed. A randomized clinical trial of
infant cereal before bedtime did not show improved sleep.85
A randomized trial of early introduction to solid food at 3
months versus exclusive breastfeeding to 6 months showed
an average of 17 minutes increased sleep time with solids,
and fewer awakenings.86 However, in another study, there
was no improvement in sleep at 1 year of age.87 Possible
minimal increased sleep needs to be balanced against thepossibility that adding early solids may interfere with theprotective mechanisms to prevent SIDS, and lead to overweight88,89 and premature weaning.
Lighting at night. Lighting at night is disruptive to sleepand circadian rhythms.90 Blue light from digital devices (which
has a short wavelength) has been found to suppress melatoninand disrupt sleep.91 Thus, activities at night that require lighting,ABM PROTOCOL

such as pumping or changing diapers, should be minimized.
Low-intensity red lighting (which has a long wavelength) has
minimal effects on the sleep–wake cycle in mice,92 so may be
useful for circumstances that require lighting.
Use of infant tracking apps and related digital technology. Although tracking apps used to monitor infant feeding

and sleeping may be marketed with claims of reducing parental anxiety, they can paradoxically increase anxiety andreduce parent–baby interaction when observing the baby becomes replaced by checking the app.93 Apps and devices thatallow parents to monitor infant sleep from afar normalize
parent–infant separation and imply that some fundamental
aspects of infant caregiving can be outsourced to technology.93
Supporting physiological infant care
Provider practices that support physiological infantcare. Approaches such as the Possums Sleep Program,which are based on normal physiology, can help support
parents.94,95 This type of approach is an infant-centered
cued care program that can result in more consolidated
sleep when used in infants over 6 months of age and does
not negatively impact breastfeeding.96 Aggressive marketing of commercial milk formula has no place in the healthcare setting and can undermine breastfeeding and mothers’
confidence.97,98 Encouraging the family to provide household help in a culturally expected manner has been shown to
be a positive factor in preventing postpartum psychologicaldistress.99

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hazards may allow mothers to maximize their rest andwell-being if sleep deprivation is a concern. Breastfeedingwith proximate sleep may protect against sleep-related
death, and is associated with responsive infant feeding andlonger durations of any and exclusive breastfeeding.
Level of evidence: 2. Strength of recommendation: B.
3. Mitigate potential risks of bedsharing while allowing
the infant to sleep within arms’ reach. Using a sidecar
attached to the adult bed if concerns exist for hazardous
circumstances, or if hazardous circumstances could
sometimes exist (e.g., if parents occasionally use alcohol or sedating substances).
Level of evidence: 2. Strength of recommendation: B.
4. Mitigate potential risks of bedsharing by teaching safe
positioning in bed. Owing to lack of data for exclusively
pumping dyads, it is unknown whether these dyads
represent a hazardous circumstance for bedsharing. The
C-position (cuddle curl) should be taught to exclusively
pumping parents, recognizing that bedsharing is common and may occur unintentionally.
Level of evidence: 3. Strength of recommendation: C.
5. Avoid nonphysiological disruptions to maternal and infant nighttime sleep as strategies for improving parental
well-being. These include nighttime pumping, bottle
feeding, and placing the infant to sleep outside the parents’ reach. Consider a dim red light if the need forlighting is anticipated.
Level of evidence: 2. Strength of recommendation: B.

Social practices that support physiological care. Physiological infant care is best supported when mothers are able
to take sufficient time off from work after giving birth torecover, establish breastfeeding, and bond with their infant.
At least 12 weeks of paid leave is associated with improved
maternal and infant health, decreased intimate partner violence, improved infant attachment and child development,
decreased maternal and infant rehospitalizations, and increased initiation and duration of breastfeeding.100 Flexible
work schedules are important for families with infants.
Physiological infant care is also supported when partners areable to take time off from work to support the mother andbond with their infant.

6. Encourage the mother and infant to return to sleep
without interruption after nighttime breastfeeding while
bedsharing. Avoid burping the infant after breastfeeding, and avoid unnecessary diaper changes during thenight. A barrier cream applied to the diaper area canhelp prevent diaper dermatitis.
Level of evidence: 2–3: Strength of recommendation: C.

Recommendations

8. Encourage the mother to sleep when the infant sleeps,
when this is possible, and remind parents that not all
sleep must occur during the nighttime hours.
Level of evidence: 2. Strength of recommendation: B.

For each recommendation, the quality of evidence (levelsof evidence 1, 2, and 3) and the strength of recommendation(A, B, and C) are noted as defined by the strength of recommendation taxonomy criteria.101

7. Sleep training in approximately the first 6 months of life
is contraindicated, and sleep training in the first year is
not recommended. A cued care program for infant sleep
may be a physiological-based alternative for parents
who desire a sleep intervention.
Level of evidence: 2. Strength of recommendation: B.

9. Encourage the mother to get help with other householdtasks so that she can focus on breastfeeding and caring
for the infant.
Level of evidence: 2. Strength of recommendation: B.

1. Help parents understand normal physiology and to carefor their infants in a responsive manner. It is importantfor health professionals to understand the normal
physiological expectations and educate parents accordingly. Professional organizations should work to minimize the impact that advertising has on promoting
nonphysiological practices.
Level of evidence: 2. Strength of recommendation: B.

10. Encourage the safe use of baby carriers during the day
to promote physical contact with the infant. Babywearing can help mothers manage daytime tasks while
keeping the infant calm.
Level of evidence: 1. Strength of recommendation: A.

2. In the absence of hazardous circumstances, mothers
sleeping in proximity to their infants is recommended.
Breastfeeding with proximate sleep in the absence of

11. Including some supervised ‘‘tummy time’’ may be important to help achieve developmental motor goals.
Level of evidence 2. Strength of recommendation: B

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12. Avoid early introduction of solids or breast milk substitutes such as formula as a strategy to improve infant
or maternal sleep. Avoid exposure to formula marketing
materials in hospitals and health care settings.
Level of evidence: 2. Strength of recommendation: B
13. Encourage parents to directly monitor infant feeding andsleeping cues, and discourage use of tracking apps andmonitoring devices for infant feeding and sleeping.
Level of evidence: 2, 3. Strength of recommendation: C.
14. Advocate for at least 12 weeks of paid maternity leavein countries that currently do not have it.
Level of evidence: 1. Strength of recommendation: A.
Summary

Compared with many strategies that mothers may use tocope with the demands of nighttime parenting, side-lying
breastfeeding with proximate sleeping may be one of the safest
strategies for maternal and infant well-being, in the absence of
hazardous circumstances. Physiological research suggests thatit may be protective for the infant,12,49,50,52 and if the natural
physiology of proximate sleep is disrupted, these protections
are lost. Accidental suffocation death is extremely rare among
bedsharing breastfeeding infants in the absence of hazardous
circumstances.1 Other coping strategies may have more
overall adverse effects to mother and infant.
Areas for Future ResearchMore research is needed about physiological infant care,particularly in the context of diverse cultural beliefs and values. Research is needed into whether there is a role for pacifiers(dummies) in physiological infant care. Continued research
into the optimal duration of paid leave for mothers and theirpartners would be helpful. More evidence is needed on thebenefits of bedsharing and breastsleeping. It is known thatbreastfeeding is associated with a reduced risk of SIDS,15 but if
this association is causal, it is unclear what aspects of breastfeeding are protective. It is likely that the protective effect is atleast partially behavioral and not only from the milk itself, andif so, bedsharing would contribute to and confound the protective effectiveness of breastfeeding on SIDS.
More data on bedsharing in dyads who exclusively pump
are necessary to ascertain their infants’ risk of sleep-related
death. More epidemiological and videographic data on anassortment of feeding methods, including in transgenderparents, would be helpful. Finally, it would be vitally important to be able to consistently collect infant feeding dataon all cases of sleep-related death.
Authors’ Contributions

All authors contributed to the conception and drafting of
this article.
Disclosure Statement

No competing financial interests exist.
Funding Information

No funding was received for this article.

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167

ABM protocols expire 5 years from the date of publication.
Content of this protocol is up to date at the time of publication. Evidence-based revisions are made within 5 years or
sooner if there are significant changes in the evidence.
Deena Zimmerman, MD, MPH, Lead Author
Melissa Bartick, MD, MS, MPH, FABM
Lori Feldman-Winter, MD, MPH, FABM
Helen L. Ball, PhD, Senior Author
The Academy of Breastfeeding Medicine Protocol,
Committee Members:
Elizabeth Stehel, MD, Chair
Lawrence Noble, MD, FABM, Translations Chair
Melissa C. Bartick, MD, MS, MPH, FABMMaria Enrica Bettinelli, MD, FABM
Lori Feldman-Winter, MD, MPH, FABM
Laura Kair, MD, MAS, FABM
Ilse Larson, MD
Yvonne LeFort, MD, FABM
Nicole Marshall, MD, MCR
Katrina Mitchell, MD
Adora Okogbule-Wonodi, MD
Susan Rothenberg, MD, FABM
Tomoko Seo, MD, FABM
Heidi Szugye, DO
Gina Weissman, DMD
Nancy Wight, MD, FABM
Michal Young, MD, FABM
Gina Weissman, DMD
Deena Zimmerman, MD, MPH, FABM
For correspondence: abm@bfmed.org(Physiologic Infant Care Handout follows /)Welcoming a new baby can be challenging. Breastfeeding at night stimulates milk p
production.
Night breastfeeding helps your baby grow.

Sleep near your baby.
You and your baby will fall asleep more easily.
Consider using a co-sleeper attached to yourbed (also called a sidecar). Breastfeed whilelying on your side.

Feeding fromm the bottom breast.
e supported on yourBreast can bebent elbow iff desired
desired.

Avoid getting up at night. Sitting up andgetting out of bed will disrupt your sleep. Skip
most diaper changes at night. Protect yourbaby’s bottom with a barrier cream. Breastfedbabies don’t usually require burping.

Turning on lights disrupts your family’s sleep.
Avoid night-time activities that require lighting
or use a dim red light. Close electronic devices.

Breastfeed at night rather than pumpor use bottles, if you can. Your night-timemilk contains melatonin. Melatonin helps
your baby sleep. Pumping and bottle feeding
disrupt sleep.

Wear your baby in a baby-wrap
or baby-carrier. Wearing your baby keeps
baby calm. Your hands will be free to get things
done. Make sure you baby’s back is supported
baby’s face should be free.

Daytime activity may help your baby
sleep better at night. Expose your baby tonormal daytime light and noises. Include somesupervised tummy-time.

Nap when your baby naps, if you can.

Avoid feeding solids or formula toimprove sleep. Parents of formula fed babies

Focus on your baby’s behavior cues.

may experience more sleep disruption thanparents of breastfed babies. Giving solids
or formula before 6 months may decreasemilk production.

Ask for help. Other caregiv
caregivers can change,

Tracking apps are not needed.

bathe, and dress your baby. They can help withcooking, cleaning, and older children.

Instead, a cued care program for infant sleep
can help parents cope.

Bedsharing safety is very important.
Bedsharing is often unplanned. Everyone
should make their bed safe for baby. See ABM’s
Bedsharing and Breastfeeding handout.

This information is a general guide to discuss with your health care professional.
It may not apply to your family or situation.

Feeding from the top breast means you do nothave to roll over to ffeed ffrom
rom both sides.