Sleep in Infants and Young Children: Part One: Normal Sleep

Katherine Finn Davis RN, MSN, CPNP; Kathy P. Parker PhD, RN, FAAN; Gary L. Montgomery MD


J Pediatr Health Care. 2004;18(2) 

In This Article

Cultural and Socioeconomic Class Influences on Sleep Practices

Two pediatric sleep issues that are highly dependent on cultural influences are infant sleeping position and co-sleeping (or bed sharing). In the United States, most pediatric clinicians support the recommendations made by the American Academy of Pediatrics that encourage supine positioning of infants during sleep. This advice is well supported by extensive research (American Academy of Pediatrics Task Force on Infant Positioning and SIDS, 1996). The 1994 national "Back to Sleep" campaign has been highly successful in reducing the incidence of sudden infant death syndrome (SIDS), decreasing the rate by approximately 40% since its introduction (Malloy, 1998 and Willinger et al., 1998). However, studies have shown that African-American mothers and low-income mothers were more likely to place their sleeping infants in the prone position (Johnson et al., 1999; Ray et al., 1997; Saraiya et al., 1998; Willinger et al., 1998 and Willinger et al., 2000). These findings suggest that there may be cultural and socioeconomic influences driving parental decisions regarding their infant's sleeping position, although the exact reason is not known. Therefore, pediatric practitioners should be aware of the decreased rates of supine positioning in these populations and attempt to clarify the benefits in a culturally sensitive manner.

Co-sleeping is a topic that has sparked passionate debates for many years. The prevailing medical opinion in the United States is that co-sleeping is to be discouraged, despite research that is unable to clearly demonstrate that co-sleeping is universally unsafe (American Academy of Pediatrics Task Force on Infant Positioning assnd SIDS, 1997). This medical viewpoint reflects American culture, which places a high value on early childhood independence. However, co-sleeping is prevalent worldwide, particularly in non-industrialized countries, and is recently becoming more widespread in the United States. Between 1993 and 2000, the percentage of co-sleeping infants more than doubled from 5.5% to 12.8% (Willinger, Ko, Hoffman, Kessler, & Corwin, 2003), and 65% of surveyed caregivers stated that sleeping with children was acceptable (Weimer et al., 2002). Co-sleeping has been found to be a relatively normative practice in low-income households (Brenner et al., 2003). Co-sleeping has also been reported to be two to four times as common in Asian and African-American families, respectively, as compared to Caucasian families (Willinger et al., 2003). Given that the practice of co-sleeping is prevalent and appears to be influenced by cultural factors, health care providers must be aware that their recommendations should be culturally sensitive, openly discuss the risks and benefits of the practice with parents, and include safety advice if parents choose to co-sleep. See Table 2 for talking points for practitioners to use when discussing the risks and safety considerations of co-sleeping with parents.


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