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The following letter appeared in the November
issue of The Archives of Adolescent and Pediatric Medicine, which is a
publication of the American Medical Association. I have included the entire
text, as it contains lots of interesting information and many good references.
"Don't sleep with your baby or put the baby
down to sleep in an adult bed." Ann Brown, chair of the US Consumer
Product Safety Commission (CPSC), voiced this statement in the September
30, 1999, New York Times through a CPSC press release.
The release previewed data from an October 1999
Archives of Pediatrics and Adolescent Medicine study entitled "Review
of Hazards Associated With Children Placed in Adult Beds."1 The news
flew over the Associated Press wires, and emotionally charged commentaries
were printed in newspapers and magazines nationwide, a clear indication
of the public interest on this issue. Numerous websites espouse the benefits
of cosleeping, also reflecting current interest in the family bed concept.2
Historically,
cosleeping in this country was the normal practice.3
Today, the practice
of cosleeping is standard for most non-Western cultures and is common
in the United States,4 yet it is probable that many pediatricians in this
country, like the CPSC chairperson, counsel new parents to sleep separately
from their infants. This is one of many areas where physicians may counsel
families based on few, or anecdotal data, in contrast to the recent trend
toward evidence-based medicine.
What
are the potential risks and benefits of cosleeping?
Are there enough data to support encouraging or
discouraging this common practice? This commentary will review the relevant
literature on this subject, enabling pediatricians to more knowledgeably
counsel families about cosleeping.
Potential Benefits of
Cosleeping
From a biological perspective, cosleeping is a natural
extension of infant care practice. Among mammals, human infants are born
the most neurologically immature, needing close human contact for basic
survival.5 Mammals need close physical contact for more than just nutritional
needs. Harlow's6 work demonstrated that newborn monkeys separated from
their mothers spent significantly more time in contact with a cloth surrogate
mother than a wire one, even if the wire surrogate provided all of the
infant's nutrition.6
Recent work by Mosko et al7 has shown that the sleep
architecture of infants who cosleep is qualitatively different. Healthy
mother-infant pairs were studied in the sleep laboratory sleeping either
alone or together. While bed sharing, infants had significantly longer
total sleep time, a greater duration and percentage of stage-1/2 sleep,
and shorter duration and lower percentage of stage-3/4 sleep (quiet sleep).
The authors postulate that if sudden infant death
syndrome (SIDS) is caused by an arousal deficiency, then less time spent
in quiet sleep through cosleeping may be protective.
This same group observed patterns of breast-feeding
in the sleep laboratory between those who routinely coslept and those
who did not.8 For infants who routinely bed shared, the number and duration
of breastfeeding episodes were significantly greater on the bed-sharing
night. The authors concluded that bed sharing promotes breastfeeding.
There are many professionals and parents who strongly
advocate cosleeping as the optimal way to raise a child. Sears,9 author
of Nighttime Parenting, advocates "attachment parenting," a
concept that includes the possibility of various sleeping arrangements,
depending on the needs of the family.
Cosleeping and SIDS
According to the Centers for Disease Control and
Prevention's (Atlanta, Ga) surveillance data between 1980 and 1994, SIDS
was the leading cause of death among infants aged 28 to 364 days, accounting
for 33% of all postneonatal deaths.10 The annual rate of decline of SIDS
deaths in the United States was more than 3 times faster from 1990 to
1994 than from 1983 to 1989; the latter dates coincide with national efforts
placed on educating families about therisks
of prone sleeping.
Does cosleeping increase the risk of SIDS? Several
studies have attempted to answer this question.11-16 Table 1 summarizes
results from the 3 most recent and comprehensive investigations. These
studies drew similar conclusions: there is no detectable increased risk
of SIDS from cosleeping unless the mother smokes.14-16 Recall bias and
residual confounding may have distorted results from these studies. However,
point estimates for the relative risk of SIDS while cosleeping (and smoke
free) were remarkably similar and close tounity
in all 3 studies.
Cosleeping and Suffocation
Another major concern involving the practice of
cosleeping is the risk of suffocation, a fear dating back to biblical
times.3 (In 1 Kings, chapter 3, one woman accuses another of having "overlaid"
her newborn.)
Drago and Dannenberg17 reviewed 2178 case summaries
from the CPSC Death Certificate Files from 1980 to 1997, for infants younger
than 13 months, whose deaths were attributed to mechanical suffocation.
The leading pattern (40% of cases) of suffocation
was wedging (infant is trapped between 2 products or parts of a product).
More than half of the wedgings involved a bed; 22% occurred in a crib.
Further investigation revealed that many of these cribs did not meet current
federal crib standards. The second leading cause (24% of cases) of suffocation
death was due to oronasal obstruction from bedding, pillows, and plastic
bags. The third cause (8% of cases) was from infants being overlain by
another person.
A more recent article, published in Archives of
Pediatrics and Adolescent Medicine in October 1999, reviewed the CPSC's
databases from 1990 to 1997 for deaths of children aged younger than 2
years who were placed in adult beds, day beds, and waterbeds.1 There were
515 deaths in children younger than 2 years who were placed to sleep in
an adult bed, with 394 of these deaths attributed to entrapment in the
bed.
A total of 121 deaths were attributed to overlying
by a parent, sibling, or other adult. During the same period, there were
17 deaths of children older than 2 years sleeping in adult beds, 8 of
which occurred in severely disabled children. Although the authors did
not investigate deaths of children placed in cribs, they did cite another
CPSC study from 1989 to 1991, which found an average of 50 accidental
deaths per year in cribs, compared with an average of 64 deaths per year
in adult beds.
The authors maintain that mothers should be encouraged
to breastfeed, but recommend they be "alerted to the hazard of overlying"
if the mother and infant fall asleep together after feeding, which is
likely to be a common occurrence.
Unfortunately, the CPSC data only represent a case
series and are not denominator-based, making it impossible to ascertain
the relative risk of death for infants who cosleep. There is also no possibility
of ascertaining the accuracy of the information derived from the databases.
Last, how many infants were sleeping with parents impaired by alcohol
or other drugs? How many were sleeping with a sibling vs a parent (another
potential risk factor14)?
To put the risk of suffocation into perspective,
the postneonatal injury death rate per 100,000 live births of white infants
in 1994 was 22, of which nearly a third were due to suffocation. This
is less than one tenth of the mortality rate from SIDS for the same cohort.17
The American Academy of Pediatrics has issued a
statement on this topic.18 Although cosleeping is not encouraged, it is
not discouraged either, assuming that the sleep environment is otherwise
safe, the infant is supine, and cosleepers do not smoke or use other drugs
that impair arousal.
Recommendations
To my knowledge, to
date, the literature offers insufficient data to recommend or discourage
babies and parents from cosleeping. Meanwhile, many parents and health
care professionals believe that cosleeping is the best way to raise a
baby physiologically, psychologically, and emotionally.
Therefore, are pediatricians
justified in condemning the family bed, making parents feel guilty about
harming their baby? Clearly, pediatricians must counsel families about
the dangers of smoking, drinking alcohol, or taking drugs that impair
arousal, and the potential for infant suffocation in beds, cribs, and
bedding. However, until there is more compelling evidence, the decision
to cosleep, like many other child rearing practices, should be left to
the family.
Catherine Kelley, MD
University Hospital
H6/466 Department of Pediatrics
600 Highland Ave
Madison, WI 53792
Archives
of Adolescent and Pediatric Medicine, November 2000; 154
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