SUPPLEMENT ARTICLE Infant Sleeping Arrangements and Practices During the First Year of Life Fern R. Hauck, MD, MSa, Caroline Signore, MD, MPHb, Sara B. Fein, PhDc, Tonse N. K. Raju, MDb aDepartments of Family Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia; bPregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland; cCenter for Food Safety and Applied Nutrition, Department of Health and Human Services, Food and Drug Administration, College Park, Maryland The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT OBJECTIVES. Our goal was to examine the sleeping arrangements for infants from birth to 1 year of age and to assess the association between such arrangements and maternal characteristics. www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1315 METHODS. Responses to the 3-, 6-, 9-, and 12-month questionnaires from the Infant doi:10.1542/peds.2008-1315o Feeding Practices Study II were analyzed to assess sleep arrangements, including bed The findings and conclusions in this article sharing, the latter defined as mother ever (in a given time frame) slept with the are those of the authors and do not infant on the same sleeping surface for nighttime sleep. Women were also asked necessarily represent the official position of the Food and Drug Administration or the about the reasons for bed sharing or not bed sharing. Eunice Kennedy Shriver National Institute of Child Health and Human Development. RESULTS. Approximately 2300 women responded at 3 months, and 1800 at 12 months. At 3 months, 85% of the infants slept in the same room as their mother, and at 12 Key Words sleep, sudden infant death syndrome, SIDS, months that rate was 29%. At 3 months, 26% of the mothers did not use the suffocation, infant mortality, risk reduction, recommended supine position for their infant’s nighttime sleep. The rate of non- health campaigns, breastfeeding compliance increased to 29% by 6 months and 36% by 12 months. The bed-sharing Abbreviations rates were 42% at 2 weeks, 34% at 3 months, and 27% at 12 months. Approximately SIDS—sudden infant death syndrome two thirds of those who bed shared with their infant also shared the bed with their AAP—American Academy of Pediatrics IFPS—Infant Feeding Practices Study husband or partner, and 5% to 15% shared it with other children. The major reasons aOR—adjusted odds ratio for bed sharing were to calm a fussy infant, facilitate breastfeeding, and help the CI—confidence interval infant and/or mother sleep better. The major reasons for not lying down with the SES—socioeconomic status infant were safety concerns. Non-Hispanic black mothers were more likely than Accepted for publication Jun 4, 2008 non-Hispanic white mothers to use nonsupine infant sleep positions and to bed Address correspondence to Fern R. Hauck, MD, MS, University of Virginia, Department of share. Family Medicine, PO Box 800729, Charlottesville, VA 22908-0729. E-mail: frh8e@ CONCLUSIONS. More than one third of the women in this cohort were noncompliant virginia.edu with safe-sleeping guidelines when their infant was 3 months old. Health care PEDIATRICS (ISSN Numbers: Print, 0031-4005; providers need to advise parents of current recommendations and discuss the risks Online, 1098-4275); published in the public domain by the American Academy of and benefits of their choices for infant sleeping practices. Pediatrics 2008;122:S113– Pediatrics S120 HE RATE OF sudden infant death syndrome (SIDS) in the United States was 5.4 in 10 000 live births in 2005.1 This Trate represents a significant decline over the past decade, which has been largely credited to more infants being placed to sleep in the supine position for all sleep periods.2 The recommendation for nonprone sleep was first made by the American Academy of Pediatrics (AAP) in 1994 and then adopted and promoted by the national Back to Sleep campaign in 1996. The AAP has continued to publish additional guidelines for reducing the risk of SIDS and other sleep-related deaths on the basis of review of newly published studies. The most recent recommendations, published in 2005,2 were also adopted by the Back to Sleep campaign.3 Parents often follow the advice to place their infant supine only during the immediate post–hospital-discharge period, changing to the less safe side or prone position when infants reach 2 to 3 months, which is the peak age for SIDS.4,5 Thus, it is important to know the prevalence of parents’ choices and practices related to infant sleep positions and to understand the factors that predict noncompliance with this important recommendation. In the published literature, the terms “bed sharing” and “cosleeping” have often been used interchangeably6 to describe a variety of sleeping arrangements. Overall, the practice of bed sharing is becoming more prevalent in the United States and in other industrialized countries.7–9 Some organizations, researchers, and clinicians promote this practice to facilitate breastfeeding.6,10–14 However, because of concerns about infant safety, other professional societies and researchers do not endorse this practice.2,15 The current AAP guidelines for reducing the risk of SIDS recommend using a “separate but proximate sleeping environment” for infants.2 The AAP also notes that it is appropriate to take PEDIATRICS Volume 122, Supplement 2, October 2008 S113 Downloaded from www.aappublications.org/news by guest on September 25, 2021 the infant to bed for nursing, comforting, and bonding and 12 months, all women were also asked why they did but recommends that the infant should be returned to a or did not bring the infant to bed with them. separate crib or bassinet when the mother is ready to Bed-sharing mother-infant dyads were identified on sleep.2 In addition, the US Consumer Product Safety the basis of answers to several questions as described Commission recommends that infants sleep in cribs until below. All women were asked if they “ever lie down or they are 2 years old.16 sleep with your baby at night” in each time frame, as Although a number of studies have shown that bed- noted earlier. The response choices for this question sharing rates are high, neither the longitudinal trends in were “Yes, with the baby in a co-sleeper,” “Yes, in a bed bed sharing nor the reasons mothers chose to bed share (standard mattress),” “Yes, in a waterbed,” “Yes, on a or not to bed share have been well studied. Therefore, mattress on the floor,” “Yes, on a couch or other place this study was conducted to examine the sleeping ar- that is not a bed,” and “No.” Multiple responses were rangements for infants from birth to 1 year of age, in- allowed. Contradictory responses (eg, both “yes” and cluding the manner in which infants were placed to “no” answers) were assigned as missing and not included sleep (prone, side, or supine), the place where infants in the analyses. (The contradictory response rate was 2% slept, and the reasons mothers gave for choosing to take at 2 weeks and gradually decreased to 0.3% at 12 or not take their infant to bed with them. In addition, we months.) All women who responded “no” were consid- assessed the associations between social and behavioral ered to be “non–bed sharers,” and they were asked to characteristics, including breastfeeding status, and spe- skip additional questions about sleeping arrangements. cific sleeping arrangements for infants. As explained be- The women who answered “yes” were asked, “When low, we chose a strict definition for bed sharing for this you and your baby lay down or slept together, did you study: “mother ever (in a given time frame) sleeps when usually: ‘Stay with the baby and also sleep’ or ‘Keep lying with the infant on the same sleeping surface for awake until the baby was asleep, or finished feeding and nighttime sleep.” then put the baby somewhere else while you slept?’” Only 1 response was allowed. Women who reported that METHODS they “usually stay with the baby and also sleep” formed Data-collection methods for the Infant Feeding Practices the group defined as bed sharers in this study. Finally, Study II (IFPS II) are described in detail elsewhere in this women who reported that they lay down or slept with supplement.17 Questions about infant sleeping arrange- the infant in a cosleeper were excluded from the bed- ments were asked in the postnatal questionnaires ad- sharing group. We excluded this group because we be- ministered at 3, 6, 9, and 12 months; data items from lieve that some mothers might consider using cosleepers these 4 assessments were included in this analysis. On as being compliant with safe-sleeping recommendations the 3-month postnatal questionnaire, participants were of the AAP Taskforce on Sudden Infant Death Syn- asked to report infant sleeping arrangements for 4 dis- drome, which stated: “Cosleepers (infant beds that at- tinct time periods: at infant ages 2 weeks, 1 month, and tach to the mother’s bed) provide easy access for the 2 months, and “now” (ie, at 3 months of age). On the 6-, mother to the infant, especially for breastfeeding, but the 9-, and 12-month questionnaires, participants were safety standards for these devices have not yet been asked to report arrangements “in the past 4 weeks.” established by the Consumer Product Safety Commis- Questionnaires that were returned outside of the prede- sion.”2 As noted above, bed sharing was defined as termined age ranges were excluded to minimize misclas- mother sleeping when lying with the infant on the same sification of responses according to infant age.