Is co-sleeping safe. It’s a question I’ve asked myself countless times, often in the dark hours of the night as my daughter sleeps peacefully beside me. Is there a link between co-sleeping and SIDS? As someone who never intended to co-sleep I spent hours picking apart the information on it before I did.
But recently I came across a website that made me question my decision. It suggested that I was putting my daughter in danger by letting her sleep beside me, that the studies that I had reviewed when making my decision were not up to date or invalid. It told me that co-sleeping is not safe in any circumstances. I was upset and if I’m honest, a little bit angry.
Because sleep is hard to come by as a new parent. And when you’re tired and sleep-deprived being able to make sense of the mass of contradictory information on the internet is like wading through treacle. All you want to do is keep your baby safe while getting the rest you need to get through the day.
So I dug out those studies again. I did my research and I’ve set out here everything I’ve found. Now I’m going to put a big ol’ caveat right here. I am not a medical professional and I am not going to suggest you should or shouldn’t co-sleep. But if like me you’ve spent nights waking up in a panic because you’ve had it drilled into you that letting your baby sleep in your bed is unsafe I hope that this will give you some peace of mind.
- Sudden Infant Death Syndrome (SIDS)
- What is co-sleeping?
- What is the link between co-sleeping and SIDS
- The breastsleeping debate
- Reducing the risk of co-sleeping and SIDS
- So should we co-sleep?
Sudden Infant Death Syndrome (SIDS)
So let’s backtrack a moment and talk about Sudden Infant Death Syndrome or SIDS. As a new parent this was number one on my list of fears for my baby. The idea that my baby could die in their sleep was terrifying to me. Those first few weeks the spectre of SIDS loomed heavy in my mind. But what is it?
SIDS used to be referred to as “cot death” and The Lullaby Trust, the UK’s leading charity for infant safe sleep, uses the following definition:
“Sudden infant death” is the term used to describe the sudden and unexpected death of a baby that is initially unexplained. The usual medical term for this is “sudden unexpected death in infancy” (SUDI). Some sudden and unexpected deaths can be explained by post-mortem examination, for example infections. Deaths that remain unexplained after post-mortem examination are usually registered as “sudden infant death syndrome” (SIDS), or sometimes “unascertained” or “unknown”. Babies that die suddenly over the age of 12 months may also be registered as “sudden unexpected death in childhood” (SUDC).
The National Institute for Health and Care Excellence (NICE) describes SIDS as “a serious, rare and unpredictable event”. In the UK around 216 babies die as SIDS deaths according to the latest available data on deaths (spanning 2006 to 2016). As the cause of SIDS is unknown and may vary from case to case there is no definitive way to prevent SIDS.
However, based on a growing base of research there are a number of risk factors that have been identified. For example, the rate of SIDS deaths in the UK fell dramatically from 1989 to 1992 following a campaign to educate parents on the important of putting their babies to sleep on their backs as a result of result identifying a link between babies sleeping in a prone position and SIDS.
The Lullaby Trust has published a full evidence base of the risk factors for SIDS, based on the latest research, which runs to over 50 pages. In this post I am only looking specifically at co-sleeping and whether this increases the risk of SIDS but I would encourage you if you are interested in other risk factors to read the full evidence base.
What is co-sleeping?
The Lullaby Trust refers to co-sleeping as “the practice of sharing a bed, sofa, armchair or other surface with an infant for sleep, which can take place either intentionally or unintentionally”. It estimates that the overall prevalence of bed-sharing in the UK is 13.9% (based on 9 studies). In its infographic for health care professionals on safe sleep Unicef UK puts the estimate slightly higher at 22%.
When I asked on my Instagram stories how many people had co-slept with their baby (whether intentionally or not) the overwhelming majority said that they had. In fact 96% of the 45 respondents said that they had co-slept, whether intentionally or not.
Co sleeping is safe in certain situations
The Lullaby Trust evidence base
Unicef UK’s infographic contains the most up to date figures available on SIDS deaths in the UK. This document states that around 680,000 babies are born in the UK each year (based on data from the Office of National Statistics) and around half of these will end up sleeping in an adult bed with one or both parents (whether intentional or not) (Blair et al (2004), “The prevalence and characteristics associated with parent-infant bed-sharing in England.”).
In 2017 the number of SIDS deaths was 183, which accounts for 0.03% of all births (again this is based on data from the Office of National Statistics). Previous data suggests that:
- Half of SIDS deaths occur when a baby is sleeping in a cot or moses basket
- Half of SIDS deaths occur when a baby is co-sleeping (ie an adult and a baby sleeping together on any surface such as a bed, chair or sofa)
BUT of those SIDS deaths where a baby is co-sleeping 90% are due to hazardous situations that are largely preventable (Blair et al. (2009), “Hazardous co-sleeping environments and risk factors amenable to change: case-control study of SIDS in south west England.” )
So that means we need to look closer at what counts as co-sleeping because there are situations where co-sleeping is safe and situations where it is not.
What is the link between co-sleeping and SIDS
The majority of studies over the past 20 years have found that co-sleeping increases the risk of SIDS. But a review into co-sleeping and SIDS undertaken by NICE found that bias and other deficiencies exist in all of the SIDS case-control studies examining SIDS so far i.e. the evidence base is unreliable.
Why is this the case? Well understandably studies into SIDS have to rely on retrospective data collection. Studies therefore match cases where an infant’s death has been attributed to SIDS with controls (i.e. a family where a baby has not died). If the controls are not carefully selected and matched then there is a risk of bias.
The studies looking at SIDS are all observational (most studies are based on interviews with parents of infants that have died and a control group). As a result, it is difficult to draw conclusions from these studies as any observed associations between co-sleeping and SIDS could be due to a number of explanations including chance and bias.
NICE concludes in its clinical guideline on infant care that there is a statistical relationship between co-sleeping and SIDS (so where co‑sleeping occurs, there may be an increase in the number of cases of SIDS) but that the evidence does not demonstrate that co-sleeping causes SIDS. In this context co-sleeping means parents or carers sleeping on a bed or sofa or chair with an infant in the first year of an infant’s life.
Key to these findings appears to be the situation in which co-sleeping occurs. A 2012 meta-analysis (a study of studies) found that there were no studies showing an association of reduced SIDS for infants who bedshare (Vennemann et al. Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate?)
But a 2014 study found there was no association between SIDS and bed-sharing in the UK in the absence of key hazardous circumstances for infants under 3 months of age. In addition it concluded that the association was in the direction of protection for infants of 3 months and older. The data also showed a greatly increased association between SIDS and co-sleeping where drug, alcohol or sleeping on a sofa are involved. (Blair et al Bed-sharing in the absence of hazardous circumstances: is there a risk of sudden infant death syndrome? An analysis from two case-control studies conducted in the UK).
The authors of this study go on to argue in a 2015 article that bedsharing is not inherently dangerous in the absence of key risk factors.
The breastsleeping debate
So then we come to the breastsleeping debate. “Breastsleeping” is a term coined by Dr James McKenna who heads up the University of Notre Dame Mother-Baby Behavioral Sleep Lab. His work is often mentioned in online co-sleeping advice forums. I’ve even written about it before as it is something that I relied on heavily when making my own decisions about whether to co-sleep.
So why is Dr James McKenna so controversial? Many of his critics point out that he is an anthropologist rather than a medical doctor. On that front I would say that the criticism seems to misunderstand what anthropology is, as it covers biological and cultural anthropology. Both these fields appear relevant to the study of the relationship between breastfeeding and infant sleep.
Another criticism is that he excludes those studies that do not support his conclusions. Whether a study can be relied upon in future research is a tricky point, particularly in this area. As I’ve outlined above independent review bodies such as NICE conclude that there are issues around bias in the studies on co-sleeping and SIDS. So it’s not completely unreasonable for a researcher to criticise previous studies (and I use criticism here in a non-pejorative sense).
So what do we know about breastfeeding, co-sleeping and SIDS? Unicef UK concludes that sleeping in close contact helps babies to settle and supports breastfeeding which in turn protects babies from SIDS. In making this conclusion it refers to four studies:
- Ball et al, “Bed-sharing by breastfeeding mothers: Who bed-shares and what is the relationship with breastfeeding duration?” (2016)
- Ball et al “Randomised trial of infant sleep location on the postnatal ward.” (2006)
- Ball “Breastfeeding, bed-sharing, and infant sleep.” (2003)
- Vennemann et al “Does breastfeeding reduce the risk of sudden infant death syndrome?” (2009)
Note that none of these references include the work of Dr James McKenna. The Lullaby Trust does refer to one study from Dr James McKenna in reaching its conclusion that there is an association between bed-sharing and prolonged and easier breastfeeding but that a causal link has not been demonstrated. But this is just one of four studies that is referred to.
So even if we do not give credence to the concept of breastsleeping, the research does appear to support the theory that breastfeeding can be supported by co-sleeping and that this may be protective when it comes to SIDS.
Reducing the risk of co-sleeping and SIDS
There is an association between co-sleeping and SIDS but when the evidence is analysed and put together the conclusion time and time again seems to be that there are ways to make co-sleeping safer. These are:
- Non-smoker
- Sober
- Breastfed
- Full-term baby
- Baby on back
- Lightly dressed and no swaddle
- Safe surface (i.e. clear of bedding and pillow, no gaps, hard mattress)
Certainly there are unsafe co-sleeping situations, particularly sleeping on a chair or sofa. But for breastfeeding mothers bed-sharing can be safe if hazards are removed. Just like you remove anything from a cot or crib, having a clear bed and adopting a cuddle / c position (arm above baby’s head, baby’s face to breast, legs bent under baby) greatly reduces the risk of SIDS.
So should we co-sleep?
When I asked on my Instagram stories only 4% said that they had not co-slept with their babies. But 27% were concerned about the risks of SIDS when co-sleeping. Whilst these surveys are not particularly scientific it does illustrate the point that even parents that are concerned that there is a link between co-sleeping and SIDS have ended up co-sleeping at some point.
The Lullaby Trust refers to two studies that suggest that blanket advice telling parents not to co-sleep may do more harm than good as it is more likely to lead to risky and unsafe practices.
The Lullaby Trust, NICE, Unicef UK and the American Academy of Paediatrics are all in agreement that parents should be made aware of the risk factors for co-sleeping and SIDS and be provided with guidance / resources to help them to make the co-sleeping environment less hazardous.
Only 54% had heard of the “Safe Sleep Seven”
@a.minimalist.mother Instagram poll
This makes perfect sense. When I asked on stories (again, totally unscientific) only 19% remember co-sleeping being mentioned in antenatal classes and only 54% had heard of the “Safe Sleep Seven”. Of course that is not to suggest that any of the 96% who had co-slept were doing so unsafely but it does illustrate the potential gap between parents co-sleeping and the support that they receive.
One person responded to tell me that they had actually been made to write down in their child’s red book that they would not co-sleep in any circumstances. But if health professionals take this attitude then surely it is increasing the risk of co-sleeping happening in a hazardous situation.
And many of the responses I received were to say that they had found co-sleeping to be an absolute lifesaver as it allowed them to get a decent night’s sleep but that the general attitudes to co-sleeping had made them feel unsupported and like it was something that they needed to keep quiet about.
My personal experiences co-sleeping have been overwhelmingly positive. I knew not to sleep with my baby on my chest or to fall asleep in a chair or on a sofa. But at my NCT class we were taught about co-sleeping in the cuddle position when breastfeeding at night and even though I never planned to co-sleep I was incredibly grateful that I knew how to make it safer when I did.
Learning about co-sleeping at NCT also meant that it was something that was normalised in our group. We felt comfortable talking about whether we were co-sleeping and how we were finding it.
I know for many that’s not the experience and there isn’t enough support, both from health professionals and our peers. But while SIDS tragically can never be eliminated we can change the conversation so that mums don’t have to feel terrified when falling asleep with their baby next to them.
