As a follow-up to my post on the benefits of co-sleeping, I wanted to write a post about co-sleeping safety. I think this is important because too many people either believe that it is unsafe and therefore avoid it at all costs or they don't think twice about safety and can end up putting their baby's life at risk. Co-sleeping can be safe, but it can also be very unsafe.
Is Co-Sleeping Safe?
There is a war on co-sleeping. Public institutions (sometimes in partnership with crib manufacturers) are spending our tax dollars to scare parents from bringing their babies to bed with them. The media is using fear inducing headlines and horror stories to garner readership. But here is the thing. Saying that co-sleeping is dangerous is like saying that riding in a car is dangerous. There is no way to make car travel completely safe, but no method of travel is completely safe. Most reasonable people take precautions to make car travel as safe as possible, but some idiots do stupid things like drinking and driving, not wearing a seat belt, driving too fast, or not putting their children in car seats. It is the same thing with infant sleep. Babies do die in their parents' beds. But they also die in cribs. There is no way to make either one completely safe, but co-sleeping is not inherently more dangerous than crib sleeping. In fact, when looking at the statistics on infant deaths in various sleep environments one researcher concluded that sleeping in an adult bed is twice as safe as sleeping in a crib once all factors have been considered (to be fair, other researchers have reached other conclusions, but I have yet to see a study that properly accounts for all risk factors when comparing the safety of crib sleeping with the safety of co-sleeping).
Does SIDS happen in the parents' bed?
One of the claims often made about co-sleeping is that it increases the risk of SIDS. However, several studies by McKenna and others in the 1990s showed that co-sleeping actually helps prevent SIDS (see p. 124 of Natural Parenting - Back to Basics in Infant Care):
The sensory-rich sleep environment of bed sharing, which leads to more frequent arousals during deep sleep and more light sleep, from which it is easier for the infant to arouse, appears to confer a survival advantage for children at risk of SIDS (McKenna, 1996; McKenna and Mosko, 1990; McKenna et al., 1993).
Other research reported in the same article also indicates that societies where mother-infant co-sleeping is the norm have a low incidence of SIDS in comparison with countries that practice solitary infant sleep. In fact, SIDS used to be called "crib death" (until the crib industry complained) because the place that SIDS deaths happened was in cribs and it was virtually unheard of in societies that do not use cribs.
What about suffocation or overlaying?
Many of the publications and articles designed to scare parents away from co-sleeping suggest that there is a great risk of suffocation or overlaying. However, research shows that it is not co-sleeping itself, but rather other factors present in the co-sleeping environment that create this danger (from page 125 of Natural Parenting - Back to Basics in Infant Care):
While infant suffocation as a result of overlying by the parent in a bed sharing environment is not unheard of, unsafe conditions such as parental intoxication with drugs or alcohol, parental disease, extreme parental fatigue, or marked parental obesity have been found to be present in many of these cases (Bass, Kravath, and Glass, 1986; Gilbert-Barness et al., 1991; see also Carpenter et al., 2004; Gessner, Ives, and Perham-Hester, 2001).
In fact, when unsafe conditions are not present, mothers and infants are able to respond to each other, thereby keeping the infant safe (from Dr. James McKenna):
Anthropological and developmental studies suggest that mothers and infants are designed to respond to the presence of the other, and no data have ever shown that among mother-baby pairs who cosleep for breast feeding in a safe cosleeping/bed-sharing environment that mothers are unable to sense the proximity of their babies in order to avoid smothering them. Our own laboratory sleep studies of cosleeping/bed-sharing mothers infant pairs (2 to 4 month olds) reveal that both breast feeding mothers and their infants are extremely sensitive throughout their night - across all sleep stages - to the movements and physical condition of the other. The healthy infant, which includes most infants, are able to detect instances, where for example, their air passages are blocked. They can respond very effectively to alert the mother to potential danger, and they have the physical skills to maneuver out of danger, under normal circumstances.
Normal circumstances is the key here. Normal circumstances means a safe co-sleeping environment.
What about newborns?
A few studies have found that there is some increased risk of co-sleeping for very young infants (under 8 weeks in one case and under 11 weeks in another case). However, like many other studies that advise against co-sleeping, these studies didn't fully account for factors other than bed sharing that could have been the key contributing factor (e.g. alcohol use, drug use, smoking, maternal fatigue). From my experience and reading, the issue of maternal fatigue probably comes about most often in cases where families are not co-sleeping, but end up bringing their baby into bed with them out of sheer exhaustion due to the fact that their baby is not sleeping in the crib. These parents are not used to co-sleeping and that combined with their over-exhausted state and likely a sleep environment not designed for an infant, creates additional risk factors. As such, bringing a baby into bed with you when you are exhausted and not used to having the baby there is not advisable, but that doesn't make co-sleeping with newborns in unsafe when parents plan for it appropriately.
Despite the faults in reports that advise against co-sleeping with newborns, I think it makes sense to be particularly cautious about the safety of the co-sleeping environment in the early weeks when you are less accustomed to sleeping with a baby and when your baby is not yet able to roll over or free himself if he gets into an unsafe situation.
What is Unsafe Co-Sleeping?
People are going to co-sleep. Some babies just do not sleep well unless they are in close proximity to or even touching their mother. So rather than have a mother shamefully sneak her baby into bed with her, into an unsafe environment, I think public health authorities should be informing parents about how to create a safe co-sleeping environment. Since they won't do that, I'll give it my best shot using information from experts in this field.
- DO NOT drink alcohol, do drugs or take medication: It is very important to ensure that nothing is impairing your ability to sense your baby's presence in bed. This means abstaining from alcohol before going to bed, not doing drugs and not taking medication.
- DO NOT smoke: Smoking poses a significant risk for babies (in terms of SIDS and increased chance of asthma and other conditions) and parents should not smoke in the room that the baby is sleeping in and ideally not at all in the home.
- DO NOT let a baby sleep next to an older child, pet, or adult that is not likely to sense the baby's presence: The person most in tune with the baby is a breastfeeding mother. Formula feeding mothers and fathers are less likely to sense their child's presence and should be more cautious about their co-sleeping arrangements. It is not safe to have a baby sleep with older children or pets as they can easily compromise the baby's safety.
- DO NOT use heavy adult bedding: Blankets, duvets, pillows and other adult bedding pose a suffocation risk to your baby. Ideally, all adult bedding should be removed from the bed during the early months and only introduced with extreme caution as the baby gets older. Remember that for crib sleeping, it is recommended that babies be put to bed with nothing more than a light baby blanket, so it is safest not to exceed that in your bed either. Both the parents and baby should be dressed warmly enough (but not too warm!) that they do not require additional heavy blankets to keep them warm. A lot of parents that feel they cannot go without any blanket choose to use a sheet or light blanket and only pull it up to their waist and then have baby sleep up higher away from the blanket (of course you need to consider when doing this whether you are the type of sleeper that would subconsciously pull that blanket up to your chin in your sleep).
- DO NOT let baby sleep on surfaces such as soft mattresses and waterbeds: Soft mattresses, squishy pillow top mattresses, memory foam, and waterbeds can all result in the baby sinking into the sleep surface and potentially obstructing the baby's ability to breathe. As a result, it is not safe to have an infant sleep on these surfaces.
- DO NOT let baby sleep anywhere that has crevices or spaces where the baby can get stuck: Adult beds are designed for adults and not for babies. This is too bad, considering that upwards of 70% of parents bring their baby to bed with them at some point. As a result, it is important to be cautious of any crevices or other spaces where the baby could get stuck. Ensure that the bed is flush with the wall (if pushed up against the wall) and ensure that there are no spaces between the mattress and headboard where the baby could get caught.
- DO NOT co-sleep on surfaces other than beds/mattresses: Sleeping on a couch or recliner is not safe. It is too easy for the baby to fall off or get stuck or smothered.
- DO NOT leave your baby alone on an adult bed unless the bed and room are completely safe: Some parents will choose to use a crib or bassinet when they are not sleeping with their baby (e.g. for naps, early in the evening, etc.). Some parents choose not to have a crib or other separate sleep surface and therefore need to ensure that the bed and room are completely safe, i.e. the baby cannot fall to the floor, cannot get into anything that is dangerous if exploring the room, etc. We also found using a baby monitor turned up very high and checking on the baby if we heard any noise at all provided additional security.
- BE CAUTIOUS about your impact on your baby: I explained above that breastfeeding mothers are very unlikely to overlay or otherwise hurt their baby. However, certain behaviours or characteristics of the mother can make this risk greater. People who are extremely overweight should ensure that they do not create a dip in the mattress that could create an unsafe crevice that the baby could roll into. Excessively long-hair should be tied back to prevent entanglement around the baby's neck. Parents should ensure that they do not wear clothing or jewelry that could cause the baby to suffocate or get entangled. Parents should not wear perfumes or other scented products to bed, as this can impact baby's ability to breathe clearly.
- BE CAUTIOUS about your extreme exhaustion: Parents of newborns can often be extremely exhausted. If you are overly tired, you may wish to be more cautious than usual as your extreme exhaustion may result in you being less easily woken or more likely to roll over the baby or pull covers up over the baby's head. It may be best to have your baby sleep on a separate surface in those instances, but still close by.
- DO NOT co-sleep if you and your spouse are not both committed to doing it and doing it safely: In order for co-sleeping to work and to be safe, both parents need to be committed to making it work. Dr. McKenna also advises that parents be sure that they would not think they had suffocated their baby if their baby did die of unknown causes (i.e. SIDS) in their bed. While it is unlikely, just like a baby can die of SIDS in a crib it could potentially happen in the parents' bed too and Dr. McKenna advises that parents should be sure they would not blame themselves or their spouse if something did happen to the baby.
How To Create a Safe Co-Sleeping Environment
Dr. James J. McKenna defines a safe sleep environment as follows:
Infants should sleep on firm surfaces, clean surfaces, in the absence of smoke, under light (comfortable ) blanketing and their heads should never be covered. The bed should not have any stuffed animals or pillows around the infant and never should an infant be placed to sleep on top of a pillow. Sheepskins or other fluffy material and especially bean bag mattresses should never be used. Water beds can be dangerous, too, and always the mattresses should tightly intersect the bed-frame. Infants should never sleep on couches or sofas, with or without adults wherein they can slip down (face first) into the crevice or get wedged against the back of a couch.
Since adult beds and adult sleep environment are rarely made with infants in mind, there are a number of things parents should consider doing to turn an adult bed into a safe co-sleeping environment.
- Have the infant sleep between the breastfeeding mother and a wall/bedrail: The breastfeeding mother is the one most able to sense and respond to the infant. As a result, the safest place for the infant is between the breastfeeding mother and either a wall, bedrail, or other product designed to ensure that the infant doesn't fall out of bed.
- Dress warmly, but not too warm: When sleeping with my children as babies, I always wore a long-sleeved shirt so that I didn't feel the need for a blanket to keep my upper body warm. I would dress my baby in pyjamas and a sleep sack if required, depending on the temperature.
- Consider putting the mattress on the floor: Putting the mattress on the floor is the safest way to co-sleep. This ensures that the infant doesn't sustain a fall from an adult bed and also takes away the worry about unsafe headboards and other bed parts. However, you still need to ensure that the mattress is placed flush against the wall and that there is no way for the infant to be trapped between the mattress and the wall.
- Preventing falls: There are a number of safety products that can be us Safety 1st Secure Top Bedrail and the Snug Tuck Pillow (apparently out of business now), both of which sit on top of the mattress. Another option is the Humanity Family Bed, which lays on top of a regular bed. ed to prevent falls if you choose not to put the mattress on the floor. This can include traditional bed rails as well as newer products. With any product designed to prevent falls, it is important to ensure that there aren't gaps where the infant could get caught or fall and also ensure that they come high enough above the mattress that your infant can't be pushed easily over the top of it. Some examples of products I like include the
- Creating more space: Many parents wish to create some extra space for the baby within their sleep environment. This can be achieved in a number of ways. If you have purchased a crib, one option is to side car the crib. One family that did this due to the father's obstructive sleep apnea created detailed instructions including step-by-step photos on how to side-car the crib. Some parents may choose to purchase a co-sleeper that attaches to the bed, such as the Arm's Reach Co-Sleeper that attaches to the side of the bed. Another option that doesn't create more space, as such, but that does create a seperate space for the baby is the First Years Close & Secure Sleeper. We used this product at the start with our son until we were more aware of his presence in the bed. The disadvantage of products like these is that the baby often outgrows them quickly.
- Filling in spaces: If you do find that there is a gap between your mattress and the wall when you push the bed up against the wall, you may wish to consider filling it with high density foam that is cut to size and that fills the space completely. Another option many parents use is rolled up blankets.
- Think carefully about co-sleeping with more than one child: Additional precautions are required when co-sleeping with an infant and an older child. Most importantly, the infant should not be placed to sleep next to the older child as that child could roll over, push, or otherwise hurt the baby. Often the best arrangement is for the older child to sleep in between the parents and for the baby to sleep between the mother and the wall or bed rail. Parents may also want to consider if they need additional space. Some families will use a California king mattress and others will use one of the tips in under the "creating more space" bullet to give everyone enough room to sleep comfortably.
- Safe Sleeping With Your Baby - The Latest Research (Dr. Sears)
- How the Stats Really Stack Up: Cosleeping is Twice as Safe (Tina Kimmel, Mothering Magazine)
- Guidelines to Sleeping Safe with Infants (Dr. James J. McKenna)
- Cosleeping and overlaying/suffocation: Is there a chance I'll roll over and crush my child? (Dr. James J. McKenna)
- Breastfeeding & Bedsharing Still Useful (and Important) after All These Years (Dr. James J. McKenna)
- Checklist for Safe Co-Sleeping (Elizabeth Pantley)
- Safer Sleep: Making Bed Sharing a Safer Option (Ann Douglas)
- Safe Infant Sleep (Attachment Parenting International)
- Top Ten Products for Co-Sleeping
- Co-Sleeper Product Reviews
This information has been compiled based on the research that I have done for our family. Each family should do their own independent research to determine the safety of the sleep environment they are choosing for their family.