Mother-infant room-sharing linked to reduced sleep duration, unsafe sleep practices

DeeAnne S. Jackson, MD

I believe this study will impact the way we counsel parents. When the new AAP guidelines came out last year, one of the newer pieces that attracted significant attention was the recommendation to room-share until 1 year of age. While this was new and different, what was more concerning to me at the time was that it received so much media attention while the other recommendations (with much stronger evidence behind them) did not.

These recommendations are critical to reducing sleep-related infant deaths or SUIDs, and while keeping the baby in the room with the parent is recommended, I think it is more important that the family start off with other safe sleep practices. Even in this study showed that during the first few months when the rate of SIDS is highest, there does not seem to be a significant difference between infants who room-share and those who do not up to 4 months of age.

In talking with families about these recommendations, it will be more of explaining benefits and risks of sharing rooms or of putting infants in their own rooms so that they can become independent sleepers. However, it is important to note that some families may not have that option, including those living in a multifamily, multigenerational household. In these situations, the parents and the infant are going to be sharing the room regardless, and sometimes they experience pressures to keep the baby quiet which may be one reason for bedsharing. Additionally, the mother could be exhausted with the limited options of either trying to get the infant quieted down and in their bed or simply bringing them into bed with her, which is one of the unsafe sleep practices we are trying to discourage.

One of the ways in which the AAP advises broaching a discussion of these recommendations is through a very nonjudgmental conversation. We cannot just walk in and say ‘you have to do this,’ without considering the family’s understanding of the recommendation. For example, what are the other pressures on them? Are we telling them one thing, but their grandmother is telling them something else? Honestly, their grandmother represents a much more important person in their life and is likely someone they respect far more than a physician that they see for a limited amount of time. It is imperative for us to try to understand where the family is coming from, because there have been some excellent studies recently demonstrating that patients acknowledge that they have received the advice and understand it, yet they still do not follow it. I think this is an area that is ripe for research. If education is not enough, how do we reach patients so that there is a safe sleep environment for a newborn?

This is a very complicated decision-making process with several difficult factors involved. We do not want our patients to only follow one aspect of a recommendation if that makes them not adhere to the other recommendations. Putting an infant on their back to sleep every time, using firm sleep surfaces, and not bedsharing are the strongest recommendations, and we need to help the parents prioritize those. We need to talk with our families and, if they are room-sharing, are they not paying attention to the other parts of the recommendation? We need to help them make decisions based on what is best for them.

Catherine Y. Spong, MD

The recent study by Paul et al reveals new information on sudden unexpected infant deaths, one of the leading causes of infant deaths and the leading cause of post-neonatal deaths. This study highlight the important role of health care providers in reducing infant risk and the persistence of disparities in outcomes. Given that sudden unexpected infant deaths account for over 35% of post-neonatal deaths, interventions have the potential for significant public health benefit.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development, along with its partners, has led efforts on safe infant sleep education since the 1990s. Beginning as the Back to Sleep campaign in 1994 and expanding to the Safe to Sleep campaign in 2012, these programs have helped raise awareness about ways to reduce the risk of sudden infant death syndrome (SIDS) and other sleep-related causes of infant death, such as suffocation. We have been fortunate to see the U.S. SIDS rates decrease by more than 60% since these efforts began.

Statistics suggest that the first 6 months after birth, when infants are forming their sleeping habits, are the most important in terms of following safe sleep recommendations to reduce SIDS risk. Research shows that 90% of SIDS deaths occur in infants younger than 6 months of age, with a peak between 1 and 4 months of age. However, because SIDS can occur at any time during an infant’s first year, parents and caregivers should continue to follow — and health care providers should continue to advise about — safe sleep practices until the infant’s first birthday.

Such conversations are most effective when caregivers can discuss sleep arrangements or situations honestly and receive appropriate feedback to help them create the safest sleep environment possible for their baby. Research confirms that advice from health care providers makes a difference in parent and caregiver decisions about sleep position and sleep environment. Helping expectant parents anticipate challenges to safe sleep and encouraging them to plan for sleep-deprived moments may help foster a more collaborative and problem-solving relationship with their provider.

Studying maturation of sleep patterns, Paul and colleagues report more optimal sleep maturation if the infant slept in a different room than the parents. These findings are in a selected population and need to be replicated in cohorts representative of the U.S. population, with consideration of confounding variables such as socioeconomic status, spousal support, and intent for exclusive breastfeeding. We agree with Paul et al that it is important for caregivers and infants to get restful and adequate amounts of sleep every night. However, we continue to encourage families to follow existing recommendations that place an infant at the lowest possible risk for SIDS and other sleep-related causes of death.

Although we have made substantial progress over the last decades in reducing sleep-related infant deaths, Paul and colleagues remind us that gaps remain. Their work adds to the ongoing basic, epidemiologic, and clinical work to uncover the causes, mechanisms, and associated factors. As a mother, researcher, and practicing OB/GYN, I want a safe sleep environment for all children — this research helps to further that important cause.