Safe sleep cuts risk of death

Do you sleep with your baby?

For millions of parents, the answer is yes.

Bed-sharing between infants and adults is common in much of the world.

And it's on the rise in the United States, as breast-feeding has become more prevalent in recent years.

But studies show the practice of adults and babies sleeping together can increase the risk of sudden infant death syndrome or asphyxiation.

Babies can suffocate accidentally in excessive bedding or when parents roll over on them without realizing it. Bed-sharing is especially dangerous if parents have been smoking, drinking alcohol or taking drugs that impair judgment or reaction time.

That's why, in 2005, the American Academy of Pediatrics, a national authority on child care, took the controversial step of recommending against adults sharing beds with babies.

"We took a lot of flak for that," said Dr. Fern Hauck, a Virginia family physician and member of the academy's SIDS task force that made the recommendation.

"We very carefully considered the pros and cons," she said. "We agonized over it. We looked at the research. There was enough evidence. Our goal is to reduce these deaths."

Critics say the recommendation discourages breast-feeding, but Hauck says mothers can successfully breastfeed their babies without sleeping together.

"I really encourage all my patients to breast-feed their babies," she said. "But I weigh that against the potential risk.

"I've talked to so many parents who lost a baby when they were bed-sharing. They say 'We didn't know. We didn't know it was unsafe.'"

To accommodate breast-feeding, Hauck suggests that when a mother finishes nursing her baby, one of the parents should place the infant to sleep on the child's back, in a safe, separate crib or bassinet in the parents' bedroom.

"I don't feel that it's a hardship on parents for the baby to be close to mom in a bassinet right near the bed," she said. "That's the safest location."

Safe co-sleeping

One of the leading opponents of the pediatrics academy's recommendation is James McKenna, an anthropologist and director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame. He was an adviser to the academy's task force and voted against the recommendation against bed-sharing.

"You shouldn't say to someone, 'Never sleep with your baby,'" he said. "It condemns parents and implies that they're not responsible. They deserve to be supported in their choice."

McKenna, author of the 2007 book "Sleeping With Baby: A Parent's Guide to Co-sleeping," said his laboratory has shown there are safe - as well as unsafe - ways to co-sleep.

"Safe bed-sharing can and does occur," he said. "A pre-requisite for safe bed-sharing is breast-feeding. It is much less likely that breast-feeding mothers will ever roll over on their infants [because] they sleep lighter, and both mother and baby are conditioned to be more sensitive."

Breast-feeding should be encouraged because it's good for babies overall, he said, but it was also found, in a 2009 study in the journal Pediatrics, to reduce the risk of SIDS by 50 percent.

McKenna describes a classic position for breast-feeding that he says should prevent a mother from rolling over on her child: The mother is on her side, in a C shape, with her knees tucked up under the baby's feet, and her arm stretched out above the baby. When the baby has finished nursing, the child stays at chest level, sleeping on its back but facing the mother. The mother's arm and bent knees would keep her from rolling over on the baby, McKenna said. And she is close enough to notice if the baby stops breathing and better able to rouse her child.

"Thousands of mothers have discovered their baby wasn't breathing in the night," McKenna said. "You never hear about the hundreds of babies that have been saved by their mothers."

McKenna agrees that babies shouldn't sleep with parents on a couch or in a recliner, or anywhere if the parents are drunk, overly tired or smoking.

Room-sharing

One area where McKenna and the pediatrics academy agree is that babies are safest if they sleep close to parents.

The academy's 2005 statement recommended "room-sharing without bed-sharing." The group cited studies that show room-sharing is associated with reduced risk of SIDS.

But McKenna said prevailing public health messages in the United States ignore the benefits of room-sharing and incorrectly imply that all co-sleeping is dangerous.

In the end, McKenna said it doesn't matter what he says or what the pediatrics academy recommends.

Parents will do what they think is right for them and their child.

Studies show that anywhere from 25 percent to 80 percent of U.S. mothers share beds with their babies either always or sometimes.

Hazards in adult beds

Despite McKenna's objections, most health experts follow the American Academy of Pediatrics and recommend against bed-sharing.

One reason: Adult beds are often draped in soft, thick blankets and piled with pillows.

"In the kind of beds we have here in the United States, it's almost impossible to safely bed-share," said Marian Sokol, president of First Candle, a national nonprofit organization dedicated to infant health.

"We get a lot of flak from the breast-feeding people who say you have to bed-share when you breast-feed. We don't feel that you do. ... SIDS is irreversible. It happens quickly, and the baby's gone. It's just not worth that kind of risk."

Dr. Preeti Matkins, a pediatrician and child abuse expert at Levine Children's Hospital in Charlotte, agrees that, in the U.S., adults beds are too hazardous for babies.

"People are sleeping on mattresses with comforters and pillows and lots of things that increase the smothering or rollover hazard. I do not recommend it," Matkins said. "It's different from sleeping on a pallet on the ground."

Effects of exhaustion

Dr. Stephanie Regenold, a Baltimore family doctor and consultant for First Candle, an organization devoted to infant health, said the chances that parents might roll over on a baby increase when they're exhausted.

"By definition, any new parent is over-tired," she said. "You can't control what you do once you're asleep. It happens very quickly."

"There's been no study to show any protective affect of bed-sharing on SIDS," she said.

Since the national "Back to Sleep" campaign began in 1994, SIDS deaths have declined as more parents place babies on their backs to sleep. That advice came after researchers concluded infants were at higher risk of sudden death if they slept on their stomachs, a position that had been recommended for many years.

Not necessarily SIDS

Today, researchers believe many of the deaths that have been called SIDS could actually have been caused by accidental suffocation. Autopsies usually can't tell the difference. So, if death scene investigations aren't thorough enough to turn up crucial evidence, infant deaths may be attributed incorrectly to SIDS.

Regenold said Baltimore health officials reviewed all sudden infant deaths during sleep from 2002 to 2008 and found that 91 percent involved unsafe sleep factors, such as bed-sharing, stomach sleeping, soft bedding or smoking by the parents.

"That was sort of alarming for us," Regenold said.

An image problem

The change in thinking about SIDS has prompted public health experts to broaden their message - it's not just "Back to Sleep" but "Safe Sleep."

That message is hard to get across when images from baby furniture stores and parenting magazines feature soft pillows, bumper pads, stuffed animals and thick blankets and comforters.

All are suffocation hazards.

"Parents have this perception that an infant needs a soft, fluffy environment," said Janice Williams, injury prevention specialist at Carolinas Medical Center. Instead, she said, the crib should be almost bare, with a firm mattress and a tight-fitting sheet so babies don't get overheated or entangled in bedding.

Some organizations in the Carolinas and across the country try to decrease the risk of infant sleeping deaths by giving cribs to needy families, but Williams said the lack of a crib isn't always a problem.

In 2005, for example, nine Mecklenburg infants died from accidental suffocation due to unsafe bedding or sleeping space.

All were from homes where cribs were present but weren't being used.

What families really need is education about how to put their babies to sleep safely, Williams said.

"We could eliminate accidental suffocation and reduce the risk of SIDS," she said. "This has been the hardest thing to get people to grasp."