How to cosleep safely with a baby

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As a new mom, I've been thinking about sleep a lot as I'm sure many parents do. I think sleep and sleep training will be a whole another episode, if not a few episodes, I have a lot of thoughts on that as well. But today, I want to talk specifically about co-sleeping. Yes, that's right. I'm a pediatrician and I want to talk about how to co-sleep. In a way, I was feeling like I'm breaking rank a little bit. I was trained, like all pediatricians, that co-sleeping is never okay. It's dangerous. But in looking at the data more closely, recently, I've come to the conclusion that is actually a little bit misrepresented, the way that we usually talk about it. So, we'll dive into that and take a more objective look at: "Is it really as dangerous as we thought, or, when is it dangerous?"; and "In what ways could it be actually beneficial? For the baby? For you?". And again, bring it all back to what do kids need? Like all pediatricians, I've given that safe sleep talk countless times.

I also work in the nursery at Beth Israel, which is one of the Harvard teaching hospitals here in Boston. And you know, on a nursery day, I'm giving this talk 30, 40 times a day and it's always no co-sleeping. They should be on their own surface. And of course, all of this is to minimize SIDS or sudden infant death syndrome. And here, I want to give a trigger warning. We are going to talk about SIDS. I think we cannot talk about co-sleeping without addressing it. But as you see, the more we dive into this issue, there are actually more new ones than we thought. But if this is triggering for you, I completely understand and I'll put a timestamp in the information below about where you can skip to if you just want the recommendations at the end of how to co-sleep more safely.

So like I said, I've given that safe sleep talk many times. But I've also known for my entire career as again, all pediatricians know that parents co-sleep quite frequently with their babies. Occasionally, someone will be, will come out and defiantly say, I co-sleep and there's nothing you can do to change my mind and sometimes parents really sound very rebellious about it because they expect talking to on the issue. More frequently. I think parents just don't say anything. It's almost like, "Oh, I know I'm going to get lectured about this. I just won't tell my pediatrician. And this is where I think, by making a blanket statement like it is always dangerous. It's never okay. It's actually stopping that conversation and stopping the opportunity of actually talking to parents about how to do it safely because they don't feel comfortable. They feel like they might be judged if they mentioned that they do it. At the same time, I think this blanket policy has actually, or I think it has actually led to more dangerous behavior, that in an effort to not co-sleep per se on the bed. Some parents will bring their babies to the couch or to another surface to feed in the middle of the night. And we're all human were so sleep-deprived, and it just happens that they fall asleep with a baby somewhere else. And unfortunately, that often ends up being way more dangerous and have caused a lot of tragic accidents. This is why the AAP, the American Association of Pediatrics actually came out in 2016 and recognized this and said actually if you're going to fall asleep with the baby, it is actually safer to do it on the adult bed than in an armchair on the couch or somewhere else. So I really commend my colleagues for making this amendment because of sticking our head in the sand, and you saying, "No, no, no, never. It's not helpful." So, with this acknowledgment that the bed is safer than other places, they just stopped short of saying, co-sleeping can be safe as well if you do it in these ways. And that's what we're going to investigate today.

Here is another thing I feel like I have to say, is that this podcast is a no-judgment zone. I just don't believe in judgment in general. I think all parents love their babies and they want the best for their babies. In fact, we put so much pressure on all these different ways to do, what's best for the babies. That's where the problem comes from. But I really think the motivation is good. No matter how you choose to sleep, I believe that you want your baby to be as safe and supported as possible. And since we always want to bring the kid back to the center of everything, in this case, if we ask what do kids need, they need one safe sleep to restful sleep or as much sleep and rest as possible. And there were three parents who are as rested and as relaxed as possible as hard as that is. As I just want to caveat this whole conversation by saying no judgment. Let's just look at the evidence. So we're going to look at the evidence against co-sleep, and for co-sleep, and think about what's best for the family.

Now, you might know that in college, I majored in anthropology for my undergraduate degree, and to this day, It really informs the way I look at many issues in medicine. And here is where I actually want to put my Anthropologist hat on for a second. And if we look at the history of babies sleeping, we'll find that in history in almost every culture babies always slept with their parents. Same with other mammals for protection, for ease of feeding, and just for general support for immature babies. In my reading, I found a fascinating historical anecdote that actually has nothing to do with medicine per se, and it is that hundreds of years ago in Europe, the Catholic priests or hearing confessions from women who admit that they were so desperate to keep the number of children down because they can't support them. That overnight they would accidentally on purpose suffocate the babies. It's very sad, and it's a desperate attempt to control the family size. Now, it's a response. The church mandated that babies should sleep by themselves for the first three years as a way to protect babies. And in the west, that was actually one of the first examples of babies being removed from their parents' beds.

Now, following this, the change in living standards also made separate bedrooms for different family members - more attractive, or more fashionable. And with the rise of Freudian Psychology, the parents' relationship became more and more sanctified. And it was thought that having the babies in the parents' room was going to disrupt that. So all these forces came together and made the practice of separating sleep more and more popular in the West as opposed to the East and other parts of the world. So let's remember that. A lot of these practices do have a cultural context to them and preferences around co-sleeping coincides with the attitude of the day. As recently as the 70s, sleep advice was that babies should be prone on their belly. Of course, that was found to lead to SIDS more than anything else. So the evidence is evolving and we should always keep in mind the context, whether that's cultural or clinical which influences the recommendations that we have.

So following these changes, a few hundred years ago in Europe, the West continues to develop a more idealization of independence and individuality, and having babies sleep apart became a part of that. And to this day, whether or not it's recommended that babies sleep with their parents culturally aligned with whether that culture sees the baby as an immature being that needs lots of nurturing and support, or it is a being that needs to be made independent as quickly as possible. I think there's no right or wrong, just like all of these beliefs it's culture, and we are a product of our culture in our times. So, just keep in mind that there is this lens to see everything. So, then, I will also say that history is not necessarily always better. I'm not saying that because we've always done it that way that is always the more natural or the superior way to do something. So, acknowledging that babies always slept with their parents, that's step one. By step two, let's look at, "Is that a good idea? Is it safe? And what are the different harms and benefits that it could have."

So, this is where we're going to talk about SIDS or sudden infant death syndrome. And I think the biggest problem on this issue is a confusion of definition. Nowadays, we say SIDS to describe infant death in the first year. And technically, the definition is actually that it's a diagnosis of exclusion, meaning, that's what we call it when we don't know what actually happened. If there's a cause for the event, whether that's suffocation or being crushed, or falling, all these terrible things that could happen, technically, it shouldn't actually be SIDS because we know what happened. And with each case, there's a thorough investigation. And oftentimes there's an autopsy, and all of these things give us clues as to what happened. If a baby was accidentally suffocated, we find evidence for that. So, technically, when we talk about SIDS, it should not include all the cases where we know what happened. So, for example, in an update from the AAP in 2016, they said co-sleeping can lead to suffocation or falling. Those are not risks for SIDS. Those are risks for accidental harm. Those are risks for accidents we can put a name on.

So for the rest of this episode, when I say SIDS, I mean a sudden infant death or we cannot find the cause. I think it's very important to make this distinction because of the danger of co-sleeping in all its forms. It's not that it leads to more SIDS. It's that it leads to more accidental harm if we don't do it safely. Let me say it again. The risk for co-sleeping is not SIDS in the sense that we don't know what happened and there's no identifiable cause. What it does lead to is a quantifiable identifiable risk for accidents. And the good news there is that knowing what happened means we can fix it or at least put things in place to prevent those very preventable accidents from happening. So, when the AAP was coming up with safe sleep guidelines that looked at all the cases of infant death and just try to associate it with the conditions under which it happened. So, yes, in a portion of this case is the baby in the parents' bed that led to some unfortunate accidents.

And that's why the point of today's episode is we're going to talk about how to prevent that or how to do it safely if you are going to co-sleep. Now, we actually don't have evidence that it increases SIDS in the sense that increases sudden infant death when we have no idea what happened. In fact, it's the opposite. There are many levels of evidence that show that co-sleeping, sleeping within a tangible distance to the parents, actually decreases SIDS which are those deaths of unknown causes. On a global level, we can just look at cultures where co-sleeping is the norm versus cultures where that is not. The country that has one of the lowest incidences of SIDS is Japan. And like many eastern countries, co-sleeping is the standard practice there. It's practiced by a large portion of the population, and it's not discouraged by pediatricians. Conversely, one of the highest incidences of SIDS is coming from the United States and New Zealand. And those two countries also have very distinct guidelines to recommend against co-sleeping. So, when we look at data, when we see two things are correlated, we cannot automatically say that's caused by it. So it's not that sleeping apart causes SIDS, but at least that association suggests that there might be some protective aspect, or at least that co-sleeping itself is not leading to more cases of these unknown reasons for accidental death.

Back in the anthropology world, another thing that we have to notice is that there are no examples of SIDS in the animal world. And to this day, we actually don't understand the pathophysiology of SIDS, which is actually what I think makes it the scariest, is we have no idea why it happens. But again, it does not happen in the animal world, and there are more and more studies modeling sleep and breathing that seem to suggest there is some symbiosis between the baby sleeping and the adult sleeping in proximity because we know that babies have very immature breathing centers. And the theory is that sleeping close to the adult can help them regulate their breathing, as well as making the adult able to respond if there is an unexpected event. And also, with babies, sometimes the way that things affect them is not immediately clear. In the small study of 25 babies between month 4 and 10, who were sleeping next to their parents, the researchers separated them for three nights. And they found that after three nights, the babies adapted very quickly to sleeping separately, and they did fine but their cortisol level which is a stress hormone remained elevated. So all these are circumstantial evidence or things that are suggestive of a reason why there seems to be less SIDS in those societies, where co-sleeping is more of the norm. And if we take a global view of anthropological data, it shows that actually sleeping alone and being a baby in the western post-industrial world is an independent factor for SIDS.

So the conclusion is if we're talking about just SIDS where we don't know why this tragic event happened, co-sleeping seems like it can actually be protective against it. At the same time, the risk factors that come with co-sleeping are identifiable and mostly changeable, which is another step we can take to actually decrease, not just SIDS, but all the accidental harm that can happen if a baby is sleeping next to an adult.

Now, as one last point of data that illustrates this nicely, in 2017, UNICEF put together the data that came out of the United Kingdom. And in that year, 0.03 percent of babies in the UK died from SIDS. And we know that one is one too many. But it really helps to look at when we have a large population, what are the trends? Now, they were split exactly half and a half whether the babies were sleeping in their own basket or caught, versus co-sleeping with parents. But of that half where they were co-sleeping with their parents, over 90% had identifiable, hazardous conditions, such as they were on the couch, the parent had been smoking or drinking, or they were chronic smokers, or the environment is unsafe in some way. So, if we remove those cases where we know actually what happened, then, the risk for SIDS drops by over 90% for the co-sleeping cohort and is actually much lower than the group that was sleeping separately.

This is in line again, with the update of recommendation from the AAP in 2016, that babies sleep in the same room as their parents, for at least six months. They stopped just short of saying co-sleeping on a bed because maybe on a population level, it's hard to sanction that knowing that there are identifiable risk factors when that happens. But, I think we know parents do this. Almost every breastfeeding mom has done it at some point. So, instead of making everyone feel guilty, I think it's much more beneficial to open enough and talk about how to do it safely.

Now, the potential benefits of co-sleeping. Number one is that it supports breastfeeding. In a practical way, it's often just easier if you have a baby that can feed lying down and it keeps you from having to get up and go out of bed. And at the University of Irvine, they did a large sleep study involving both parents and babies, where everyone's hooked up to the monitor, to watch how they sleep. And when babies and parents co-slept, they both got more sleep as in more time asleep but they were both In lighter sleep. They are more arousable and they were mostly in REM sleep, that stage where you're dreaming and you're close to waking up but you're still asleep. And the thinking is that this is part of the reason that it can be protective because the mom and the baby are remaining responsive to each other. If you're interested in further reading, I'm going to link books and articles at the end of the show note. So please be sure to check it out. I think the research is fascinating. But once we know that this risk for SIDS that everyone talks about, actually comes from identifiable and changeable factors and not from the fact that the baby's sleeping next to you. And in fact, it might be safer for them to sleep next to you for their own physiology. Then we can stop feeling bad about co-sleeping and focus on how do we do it as safely as possible.

Now, before we talk about how to do it. I do have to say that this is not medical advice. Since I am not your child's pediatrician. I cannot give you direct medical advice. And it is always up to you and your family, but if you have decided to co-sleep, I do think it's important to keep these seven points in mind. And the first one is that we're starting with a healthy term infant. If your baby is premature or there are health issues, then this changes everything that makes them more vulnerable to many conditions. For example, if their premature and their airway is not as developed, then maybe they should not feed lying down or side-lying feeding. So if you do have a baby who is not term or who has any health conditions, I do encourage you to really talk to your pediatrician about all the range of risks that might come and make sleeping arrangements based on that. I do not recommend automatically co-sleeping with a premature baby or with health or anatomical conditions.

Number 2, it really helps if you are a breastfeeding mom. Now, in the studies I linked to, they actually found that pairs of moms and babies, who breastfeed move differently. This is not a judgment on parents who do not breastfeed but specifically, in terms of co-sleeping, the evidence suggests that it's safer if you are breastfeeding. Just in the way you move together, you're less likely to end up in each other space in a dangerous way. And also just practically if you are bottle feeding in the middle of the night, then a lot of the co-sleeping benefits are not as applicable. If you have to get up anyway, out of bed, and go get the bottle and come back, you lose out on the benefit of not needing to move to feed them in the middle of the night. So for me, if you are co-sleeping, I think being a breastfeeding mom is an important condition.

Number 3, thinking about the space. Now the AAP guidelines, separately but together. Ideally, if you have an area of the bed that just gets out that they can be in without any risk of falling or there next to you within arm's reach, but they're still in their own space. That's absolutely the best. But I know that's not necessarily an option for every family that might not be the kind of crib that you bought. And the reality is many parents will bring the baby into bed with them. So, knowing that, my advice would be, to make sure, first of all, that is a space they cannot fall from. One of the safest ways I've heard of people doing this is just putting the mattress or wherever you're going to sleep on the ground. So they have nowhere to fall. Make sure the surface is firm. Definitely no water bed. No really soft mattresses that are easy to roll into a divot or get stuck in. So you want that surface as firm as their own crib would be. And also, by having a firmer surface, it's harder for you to roll into them. Make sure there's no gap or hole between the bed and the wall. When the baby's very young, of course, they can't move very much, but especially as they get older, think about all the different ways that they can move around in the bed or flip into and plan for those. So that the space is safe.

Number 4, are there people or are there pets? It's really safe so as to not have other people. So if you are bed sharing the safest possible way to do that is just to have the mom and the baby in the bed. Nobody else. No pets. No fathers. No partners. No siblings. Those are all unpredictable factors. And like I said, the breastfeeding mom and the baby, they move more in synchrony, and other people and pets, and siblings just don't have that. So, it's safest to remove those factors.

Number 5. Strictly no alcohol. No smoking. No substances of any kind that can alter you. And if you are a chronic smoker, then co-sleeping is not safe for you and your baby. So this is only if you are sober, in reasonably normal condition. Now, sometimes you can get so exhausted. I mean, everyone's pretty sleep-deprived with a new baby, but there are levels to this. So, maybe during that, those regressions, or we haven't slept in weeks and there's nobody else to help, and you're super, super tired. You're not sure that you have a normal level of responsiveness. Then I also recommend you put that separation in, just put them in their own bed.

Number 6, think about the blankets, the temperature, put them in a sleep sack or a safe sleeping device like you would in their own crib and the baby shouldn't share the cover with you because the adults blanket can be a lot bigger, and especially for a younger baby, they can roll their face into it and impede their breathing. So think ahead of time about what's keeping the baby warm go for a nice temperature in the room and then dress them safely and appropriately for that without having them underneath your cover. Especially if you breastfeed lying down, it can be easy for them to get caught into the cover once they're done, if you both fall asleep that way. So, think ahead about the blanket situation.

And, lastly, don't leave the baby alone on your bed. If you're co-sleeping safely you should also be there. Definitely not leaving the baby unattended in a space that's not their own crib. The evidence shows us that when done safely and correctly, co-sleeping can be very safe. It can actually offer wonderful protective benefits both for the baby, for both of your sleep, for their breathing, and just for that natural bonding and connection, that all babies crave that we crave too. So, if this is something that you chose to do, I hope that the guidelines have helped you become more confident that you're doing it safely. And also to give you some contacts that you are not alone in this. And there's a reason that many breastfeeding mothers naturally want to do this. So, wherever you are, and wherever you and your baby are at. I wish you as much rest and sleep and cuddling and safe connection as possible.

I hope you found this episode helpful. If you're interested in a one-on-one consultation with your own on-demand Kinder pediatrician like me, you can find us at gokinderkid.com. You can find the show notes for this episode at askdoctoramy.com. That's doctor, all spelled out and you can find me on Instagram also @askdoctoramy.