Bedsharing, Breastfeeding, and Safe Infant Sleep

Viewpoint

These two studies (one from the United Kingdom and the other from the United States) considered the issues of breastfeeding and infant sleep location from slightly different perspectives but had some similar findings. Both studies show that bedsharing while breastfeeding is a relatively common practice, and both have important implications for the nature of advice provided to parents of newborns.

Smith and colleagues found that approximately 21% of mothers "usually" bedshared, and Ball and colleagues reported that 28% of mothers "often" bedshared. In both studies, bedsharing was linked with breastfeeding. Ball and colleagues also found, like another recent US study,^[2] that longer duration of bedsharing was associated with a longer duration of any breastfeeding. Smith and colleagues limited their data collection to 2-4 months after birth, so it is not known whether this cohort of mothers continued to breastfeed for the recommended duration, or whether sleep location was related to continuing to breastfeed.

The link between bedsharing and breastfeeding has sometimes posed a dilemma for US healthcare professionals providing infant care advice. Although nurses want to support and encourage breastfeeding, the practice of bedsharing conflicts with the principles of a safe infant sleeping environment outlined by the AAP.^[1] Many have wondered whether a separate but proximate sleeping arrangement can achieve the same degree of breastfeeding success as bedsharing.^[3]

The bedsharing issue has been much debated over the years, with one side maintaining that planned bedsharing is a low-risk practice and should be encouraged for breastfeeding women.^[4]The AAP, however, states that the evidence is insufficient to recommend any bedsharing situation in the hospital or home as safe.^[1]

The issue is further complicated by the fact that breastfeeding is protective against SIDS.^[5] Whether the added benefit of breastfeeding outweighs the risks associated with bedsharing to facilitate breastfeeding is not known with certainty, but evidence shows that among even low-risk infants who were breastfed, bedsharing elevated the risk for SIDS fivefold up to the age of 3 months compared with infants who room shared without bedsharing.^[6]

How can healthcare professionals support the dual aims of safe infant sleep and breastfeeding?

First, they need to acknowledge that bedsharing happens and will continue to happen. In a previous UK study, 50% of mothers found themselves bedsharing with their infants despite prenatal opinions that they would not do so.^[7,8] Huang and colleagues^[3] found that bedsharing rates among breastfeeding women and their infants were 41.5% at 2 weeks, 34.0% at 3 months, and 27.0% at 12 months of infant age. Moreover, women who seek it will find a great deal of support for the practice of bedsharing in online forums, where the benefits of bedsharing may be emphasized more than the risks. So, simply telling women that it's unsafe to bedshare is unlikely to have a significant effect on this practice. If the healthcare community comes down too hard on mothers who admit to bedsharing for the purposes of facilitating breastfeeding, they may simply "go underground, and do it covertly."^[9]

Most mothers make decisions about breastfeeding before delivery, but not necessarily about bedsharing. Having a dialogue about the risks and benefits of bedsharing can help parents make an informed decision, if and when the issue arises. Parents also need to be aware of the factors that increase risk for accidental infant death in a bedsharing situation. The AAP specifically recommends that parents avoid bedsharing in the following potentially hazardous circumstances:^[1]

Infant aged < 3 months;
Current smoker or mother who smoked during pregnancy;
Caregiver who is excessively tired or has taken medications (antidepressants, pain medications) or substances (alcohol or illicit drugs) that can impair alertness or ability to arouse;
Any nonparent, including children;
Multiple persons; and
Soft surfaces or articles (waterbed, old mattress, sofa, couch, armchair; soft bedding, pillows, heavy blankets, quilts, comforters).

An infant may be brought into the caregiver's bed for feeding or comforting but should be returned to the crib or bassinet when the parent is ready to sleep. The AAP does not recommend the use of devices marketed to make bedsharing safe (eg, in-bed co-sleepers), which cannot guarantee safety for the bedsharing infant.^[1,10]

Regardless of the healthcare professional's personal position on the breastfeeding/bedsharing controversy, keeping the lines of communication open is a much better way to help families. Acknowledging that many women bedshare, or asking mothers about their intention to bedshare, is not the same as condoning it. It is possible to fully inform new parents of the risks that bedsharing poses to their infant's safety, and the AAP's recommendations, in a nonjudgmental fashion while still promoting breastfeeding.

It is helpful to know that advising women to adhere to both of these recommendations does not necessarily discourage breastfeeding. As Smith and colleagues demonstrate, advice from multiple sources, providing the same messages, can encourage mothers to follow both recommendations.

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