Вы находитесь на странице: 1из 6

Paediatric Respiratory Reviews 16 (2015) 62–67

Contents lists available at ScienceDirect

Paediatric Respiratory Reviews

Review

Bed-sharing and unexpected infant deaths: what is the relationship?


Peter Fleming *, Anna Pease, Peter Blair
University of Bristol, School of Social and Community Medicine, St Michael’s Hospital, Southwell St, Bristol BS2 8EG

EDUCATIONAL AIMS

The reader will come to appreciate that:

 Bedsharing with infants by parents who smoke, drink alcohol or take recreational drugs, or are sleeping on a sofa or armchair is
associated with a significantly increased risk of unexpected infant death, particularly for infants less than 3 months of age and for
those who were of low birthweight or preterm.
 Bedsharing by breastfeeding mothers with their infants, in the absence of the above mentioned risk factors, has not been shown to
be associated with a significantly increased risk of unexpected infant death.
 There is a strong bidirectional relationship between breastfeeding and bedsharing. The benefits of breastfeeding must be
considered in any advice given to mothers about bedsharing.

A R T I C L E I N F O S U M M A R Y

Keywords: For much of human history infant survival has been largely predicated by close and continuous contact
Sudden Infant Death Syndrome [SIDS]
between the infant and the primary carer – almost always the mother.
Unexpected infant deaths
Many factors in post-industrial human society - notably tobacco smoking, alcohol intake and the use
Bed-sharing
Co-sleeping of recreational drugs– have been associated with increased risk to infants sleeping in close proximity to
Smoking their mothers. This is particularly true for mothers who choose not to breastfeed.
Alcohol The question of the risks and possible benefits of bed-sharing for mothers who plan to breastfeed, do
Epidemiology not smoke, do not drink alcohol or take recreational drugs, and are aware of how to ensure a safe infant
sleep environment need to be quantified.
In this paper we review the evidence from several epidemiological studies and identify the factors that
make bedsharing more or less hazardous for the infant. This analysis is important in allowing us to give
parents accurate and unbiased information on which to make their own choices about optimal night time
care of their infants without demonising normal parental behaviour or practices.
ß 2014 Elsevier Ltd. All rights reserved.

INTRODUCTION continued growth and indeed survival for the baby that to question
the appropriateness of such a care pattern would be perverse.
For most of recorded human history, and in most societies Since the early stages of industrialisation more than 250 years
today, the normal place for human infants to sleep has been in ago approaches to child care have been subject to the effects of
close proximity to their mothers. In many historical settings and in major changes in social and political organisation and differing
some settings in which mothers and babies live in the 21st century, ideas on the role and responsibilities of parents as primary
the protection and access to breast milk afforded to the baby from caregivers and/or as breadwinners.
such close proximity was and is of such clear importance to the The effects of one such change - in the form of officially
sanctioned production and consumption of cheap gin – are
illustrated in the work of William Hogarth – notably ‘‘Gin Lane’’
and ‘‘Beer Street’’.
* Corresponding author. There can be no doubt that the infant in Gin Lane (Figure 1) –
E-mail address: peter.fleming@bristol.ac.uk (P. Fleming). sleeping on the steps with a mother incapacitated by alcohol is

http://dx.doi.org/10.1016/j.prrv.2014.10.008
1526-0542/ß 2014 Elsevier Ltd. All rights reserved.
P. Fleming et al. / Paediatric Respiratory Reviews 16 (2015) 62–67 63

The question of whether and in what circumstances the


risk of unexpected infant death was increased by sharing a
sleep surface with an adult has been greatly hampered by the
zeal with which advice, recommendations and blame have
been proffered by those on both sides of the debate, and the
relatively poor quality of the evidence upon which such opinions
have been based.
In this paper we will review the evidence of risks and potential
benefits to parents and infants from mothers (or fathers) sharing
a sleep surface with a baby in the first years after birth.

WHAT DO WE MEAN BY ‘‘BEDSHARING’’?

The differing definitions of bedsharing or ‘‘co-sleeping’’ used in


various studies have caused considerable confusion. For the
purpose of this review we will define bedsharing as the infant
sharing a sleep surface with an adult (most commonly but not
always the mother). This definition thus includes the instances
when adult carers fell asleep unintentionally with a sleeping
infant on a sofa, armchair or other surface as well as those
instances when the adult chose to share a sleep surface (e.g. a bed)
with the infant. For clarity we will avoid the term ‘‘co-sleeping’’
which we take to be synonymous with bedsharing.

PUBLISHED STUDIES ON THE RELATIONSHIP BETWEEN


BEDSHARING AND THE RISK OF UNEXPECTED INFANT DEATH

In a careful meta-analysis of published studies on the


relationship between bedsharing and the risk of Sudden Infant
Death Syndrome (SIDS), Vennemann and colleagues identified
11 case control studies that met their strict inclusion criteria [1–
Figure 1. William Hogarth. Gin Lane 1751. 12]. These observational studies were conducted between
1987 and 2006 in the UK (4 studies), the US (3 studies) and one
study each in Ireland, Norway, Germany and New Zealand.
gaining little and potentially losing a great deal by this close
The authors found that for all of the studies the effect of
proximity. Studies of infant mortality in the UK in the 19th century
bedsharing was in the direction of an increased risk of SIDS, though
drew attention to the high mortality levels associated with poor
this did not achieve statistical significance in all studies, and that
social circumstances, infection, cramped and overcrowded sleep-
the summary odds ratio (OR) for the risk of SIDS whilst bedsharing
ing conditions and high levels of alcohol consumption by parents –
compared to infants sleeping alone was 2.89 [95% CI: 1.99-4.18]
particularly mothers.
with significant heterogeneity between studies. In the combined
Improvements in infant mortality rates in the 20th century
calculation 2464 cases and 6495 controls were included, of whom
(see Figure 2) – with a 95% fall in infant mortality over the
710 cases (28.8%) and 863 (13.3%) controls bed shared.
century from 95 deaths per 1000 live births in England and
The subgroup analysis of the relationship between maternal
Wales in 1912 to10.8 deaths per 1000 in 1982, and 4 deaths per
smoking and bed sharing, from the four studies in which this data
1000 in 2012 meant that more attention was given to relatively
was available [12–15] showed a significant risk (OR 6.27 [95%
less common groups of infant deaths including sudden and
CI: 3.94-9.99]), whilst for non-smoking mothers [11,13,14] the
unexpected deaths in cots or in bed with adults.
risk was not significant (OR 1.66 [95% CI: 0.91-3.01]).
In the three studies in which bed sharing with young infants
Neonatal, Post-neonatal and Infant mortality, under the age of 12 weeks was separately reported [3,11,15]
this was identified as a risk factor (OR 10.37 [95% CI: 4.44-24.21]),
England and Wales 1982-2012
while for older infants no significant risk was identified (OR
12.0
1.02 [95% CI: 0.49-2.12]).
10.0 Routine bed sharing [11,14] was not significantly associated
with SIDS (OR 1.42 [95% CI: 0.85-2.38]), but bed sharing on the
8.0 last night by infants for whom bed sharing was not routine was
a significant risk factor [3,14–16] (OR 2.18 [95%CI: 1.45-3.28]).
6.0
In their conclusions Vennemann et al acknowledge there is
4.0 emerging evidence of a significant interaction between bed sharing
and parental use of alcohol and drugs as well as an excess of
2.0 SIDS bed sharing deaths on sofas that their meta-analysis could
not examine [12].
0.0
1982 1987 1992 1997 2002 2007 2012 Carpenter and colleagues reflected many of the same findings
[17] when pooling data from a portion of these case control
Infant mortality1 Neonatal mortality2 Postneonatal mortality3
studies. These authors used imputation in an attempt to correct
Figure 2. Infant Mortality in England and Wales 1982-2012 (Office for National for the fact that information on some of the potential
Statistics). important interactions – notably parental alcohol intake and
64 P. Fleming et al. / Paediatric Respiratory Reviews 16 (2015) 62–67

illegal drug use – was not collected or reported by the majority of When categorised by the sleep environment, the multivari-
studies. This use of imputation to estimate the likely contribution able risk of SIDS for infants who were bedsharing with an adult
of factors not actually collected in whole studies included in the on a sofa or chair, or with an adult who had consumed more than
report has been heavily criticised [18–20], as the imputation two units of alcohol was 18 times greater than for those infants
calculations were based upon observations in populations that who those who were not bedsharing; for those infants who slept
were culturally, geographically and temporally distinct between next to a parent who smoked (but had not been drinking alcohol)
the relevant studies. Thus the conclusion reached by these authors, the risk was four times greater than for those who did not
that bedsharing was associated with a markedly increased risk of bedshare. There was no significant multivariable risk of bed-
SIDS regardless of parental smoking or alcohol intake has been sharing in the absence of these hazards (OR = 1.1 [95% CI: 0.6-
called into question. 2.0]). None of the variables significant in the multivariable model
To try and address the question of whether there is a risk had more than 5% missing data and over 95% of the data were
associated with bed-sharing in the absence of hazardous used in the final model presented.
circumstances such as parental alcohol consumption, smoking Although the risk for pre-term infants who bedshared
or the use of sofas we pooled individual data from two of our SIDS (Table 2) was more marked (OR = 7.0 [95% CI: 3.0-16.4]) than
investigations; the 1993-6 CESDI study and the 2003-6 ‘‘SWISS’’ those who did not (OR = 3.9 [95% CI: 2.6-5.8]), the interaction
study in the UK [2,5,13,21]. was not significant.
In this analysis [21] of 400 SIDS deaths and 1386 age-matched Parents were more likely to bedshare with a male infant.
controls we utilised a detailed data collection using similar Amongst non-bedsharing infants 50% of the controls were male
protocols and questionnaires in separate UK studies 10 years apart whilst 64% of the SIDS infants were male, confirming the well-
[2,5,13]. Importantly information was collected on the position of recognised higher male vulnerability to SIDS. However, despite the
the baby in relation to each parent when more than one parent higher proportion of bedsharing male infants (65% of the controls)
was in the bed – i.e. who was next to the baby, and whether the there was no disproportionate excess of deaths amongst male
baby was adjacent to one parent or between the two - to determine infants (68% of bedsharing SIDS were male). The explanation of
whether the relevant adult was sleeping adjacent to the infant, these gender differences is unclear.
thus potentially putting the infant at risk. Because of the very high Similarly, breastfeeding was more prevalent amongst those
levels of completion of data collection in both studies data who bedshared, thus there was no difference in the breastfeeding
imputation was not used. rate between the bed-sharing cases and controls and the apparent
In order to separate the effects of different co-factors and protective effect of breastfeeding against SIDS was found only
attempt to quantify the risk in the absence of known risk factors, amongst those who did not bedshare (OR = 0.3 [95% CI: 0.2-0.5]).
we used a hierarchical approach to consider the potential adverse Despite the common association found in most observational
effects of such risk factors on infants who were bedsharing. On the studies between socioeconomic deprivation, larger families,
basis of previous findings from several studies we first identified younger mothers and SIDS, this differential was stronger amongst
those infants (cases and controls) who were bedsharing on a those who did not bedshare.
sofa, as the known highest risk sleeping environment, regardless Being found with the head covered was more common amongst
of whether the parents smoked or had drunk alcohol. Having infants who did not bedshare – both cases and controls.
identified this group, the next group was those infants bedsharing A novel and unexpected finding using this combined dataset
with a parent or parents who had drunk more than 2 units of was that the apparent protective effect of pacifiers (dummies) was
alcohol; having identified these two groups the next group was mainly confined to those who bedshared (OR = 0.3 [95% CI: 0.2-
infants bedsharing with a parent or parents who smoked, and 0.5]) although the result was just significant for those who did not
finally the last group and the group of interest was infants (OR = 0.8 [95%CI: 0.6-0.997]).
bedsharing with one or two parents in a parental bed, and where Interestingly the risk associated with placing infants prone was
neither parent smoked or had drunk alcohol. The results of this absent among those who bedshared (OR = 0.4 [95% CI: 0.2-1.2]) but
analysis [21] are shown in Table 1. strongly significant among those who did not (OR = 11.3 [95% CI:
Over a third of SIDS infants (36%) were found bedsharing with 7.0-18.4]), yielding a highly significant interaction (p < 0.0001).
an adult at the time of death compared to 15% of the controls after This confirms our previous findings from the Avon longitudinal
the reference sleep. In a multivariate analysis, adjusted for a wide data of SIDS infants over a 20 year period in that the ‘Back to Sleep’
range of known risk factors, the overall odds ratio for SIDS for all campaign had much less effect on bed-sharing deaths as placing
infants who bedshared, was 3.91 [95% CI 2.72 – 5.62]. infants prone is much more uncommon amongst bed-sharing

Table 1
The risk associated with co-sleeping overall and by different co-sleeping environments [21]

SIDS Controls Univariable Risk* Multivariable Risky

Overall N (%) N (%) OR [95% CI] P-value OR [95% CI] P-value

Did not co-sleep for the last sleep 255 (63.8%) 1173 (84.6%) 1.00 [Ref Group] 1.00 [Ref Group]
Co-slept for the last sleep 145 (36.3%) 213 (15.4%) 3.19 [2.47-4.12] <0.0001 3.91 [2.72-5.62] <0.0001
By different co-sleeping environments
Did not co-sleep for the last sleep 255 (63.8%) 1173 (84.6%) 1.00 [Ref Group] 1.00 [Ref Group]
Co-slept on a sofa or chair 33 (8.3%) 7 (0.5%) 21.47 [9.38-49.17] <0.0001 18.34 [7.10-47.35] <0.0001
Bed-shared next to adult (>2 units of alcohol) 29 (7.3%) 12 (0.9%) 11.34 [5.69-22.57] <0.0001 18.29 [7.68-43.54] <0.0001
Bed-shared next to adult who smoked 59 (14.8%) 63 (4.5%) 4.37 [2.98-6.41] <0.0001 4.04 [2.41-6.75] <0.0001
Bed-shared in the absence of these hazards 24 (6.0%) 131 (9.5%) 0.86 [0.54-1.36] 0.51 1.08 [0.58-2.01] 0.82
*
Adjusted for infant age and whether a day or night sleep. The logistic regression model using all 1786 individuals
y
Adjusted for infant age and whether a day or night sleep as well as infant characteristics: birthweight < 2500 g, pre-term, male gender and currently breastfeeding,
maternal characteristics: larger families (3 children), younger mothers ( 21 years) and poor maternal education (< GCSE or no qualification) factors at the time of the last
sleep: infant unwell (scoring more 8 or more on the Babycheck), infant placed prone or side, infant swaddled, use of a duvet, use of a dummy and infant found with head
covered.
The logistic regression model using 1700/1786 (95.4%) individuals.
P. Fleming et al. / Paediatric Respiratory Reviews 16 (2015) 62–67 65

Table 2
Interactions with co-sleeping and significant predictors of SIDS [21]

Infants who co-slept Infants who did not co-sleep Interaction*

SIDS Controls SIDS Controls P-value

Infant Characteristics N (%) N (%) N (%) N (%)

Low Birthweight < 2500g 29/145 20.0% 11/210 5.2% 58/255 22.7% 57/1168 4.9% 0.79
Pre-term (<37 weeks gestation) 29/145 20.0% 7/202 3.3% 47/253 18.6% 65/1165 5.6% 0.20
Male gender 91/145 62.8% 139/213 65.3% 163/255 63.9% 589/1173 50.2% 0.01
Still breastfeeding prior to last sleep 64/145 44.1% 98/213 46.0% 24/255 9.4% 287/1172 24.5% 0.001
Maternal Characteristics
Larger families (3 children) 56/145 38.6% 32/213 15.0% 114/255 44.7% 272/1173 23.2% 0.33
Younger mothers (21 years) 41/145 28.3% 31/213 14.1% 87/255 34.1% 161/1173 13.7% 0.27
Poor maternal educationy 53/135 39.3% 30/211 14.2% 101/247 40.9% 232/1169 19.8% 0.27
Factors at the time of the last sleep
Whether last sleep was a day or night sleep 11/145 7.6% 12/213 5.6% 56/255 22.0% 212/1173 18.1% 0.87
Infant placed in the side position to sleep 50/141 35.5% 58/212 27.4% 92/251 36.7% 312/1170 26.7% 0.75
Infant found with head covered by bedding 11/134 8.2% 2/212 0.9% 42/246 17.1% 36/1164 3.1% 0.64
Infant swaddled for sleep 24/143 16.8% 16/213 7.5% 41/251 16.3% 108/1173 9.2% 0.52
Infant being unwellz 41/145 28.3% 31/213 14.1% 87/255 34.1% 161/1173 13.7% 0.27
Infant covered with a duvet 72/142 50.7% 88/212 41.5% 78/253 30.8% 187/1173 15.1% 0.07
Infant used a dummy for sleep 29/134 21.6% 102/211 48.3% 106/249 42.6% 580/1172 49.5% 0.001
Infant placed in the prone position to sleep 5/141 3.5% 17/212 8.0% 53/251 21.1% 27/1170 2.3% <0.0001
Younger infant (<98 days) at time of last sleep 111/145 76.6% 106/213 49.8% 110/255 43.1% 566/1173 48.3% <0.0001
*
P-value of the interactive term (variable of interest x co-sleeping variable) in a model including both these factors as well as infant age and, whether a day or night sleep
y
defined as qualifications below those expected at 16 years old (i.e. below GCSE level or no qualifications)
z
defined as those infants scoring 8 or more on the Babycheck indicating the infant was unwell

infants [22]. There was also a strong interaction (p < 0.0001) occurred beyond 3 months of age when bed-sharing in the absence
with infant age; bedsharing was a much greater risk for those of alcohol, smoking or sofa-sharing. Even if we just use the upper
infants younger than the median age of 98 days (OR = 3.3 [95% confidence interval, the risk of SIDS was apparently halved in
CI: 2.1-5.3]). this particular group of infants (OR = 0.1 [95% CI: 0.01-0.5]).
In Table 3 [21] the data has been split to look at the risk of
bedsharing in younger and older infants; dichotomising by using THE RELATIONSHIP BETWEEN BEDSHARING AND OTHER
the median of 98 days old. Overall the risk of bedsharing among the OUTCOMES FOR INFANTS AND CHILDREN
younger infants increased to fivefold while the risk among the
older infants became non-significant. Looking in more detail at the Several studies have shown a strong relationship between
different bedsharing environments, the numbers in some of the routine mother-infant bedsharing and the successful initiation and
categories were very small so caution needs to be taken regarding maintenance of breastfeeding [23–26]. The major benefits to the
the point estimates. The risk of bedsharing with a parent on a sofa infant from being breastfed are well-known, and include an overall
or chair was high regardless of infant age. The risk of bed-sharing lower infant mortality rate, even in western societies [27].
next to a parent who had consumed more than two units of alcohol However, very few studies have investigated the relationship
was higher among younger infants, but still posed a six-fold risk for between routine bedsharing in infancy and early childhood on
older infants. The risk of bed-sharing next to a parent who smoked long-term outcomes for surviving infants (Table 3).
was largely confined to the younger infants while the risk of bed- In a study utilising data collected as part of the Avon
sharing in the absence of these hazards was not quite significant Longitudinal Study of Parents and Children (ALSPAC) we investi-
among the younger infants (OR = 1.6 [95% CI: 0.96-2.7]) and gated the effects of routine sleep practice in early childhood –
seemingly protective among the older infants. Only one SIDS death including whether the infant or child shared a bed with a parent

Table 3
The risk associated with co-sleeping overall and by different co-sleeping environments in younger and older infants [21]

Younger infants (<98 days) Older infants (98 days)

SIDS Controls OR [95% CI]* P-value SIDS Controls OR [95% CI]* P-value

Overall N (%) N (%) N (%) N (%)

Did not co-sleep for the 110 49.8% 566 84.2% 1.00 [Ref] 145 81.0% 607 85.0% 1.00 [Ref]
last sleep
Co-slept for the last sleep 111 50.2% 106 15.8% 5.24 [3.71-7.39] <0.0001 34 19.0% 107 15.0% 1.40 [0.91-2.15] 0.13
Different co-sleeping N (%) N (%) N (%) N (%)
environments
Did not co-sleep for the 110 49.8% 566 84.2% 1.00 [Ref] 145 81.0% 607 85.0% 1.00 [Ref]
last sleep
Co-slept on a sofa or chair 22 10.0% 5 0.7% 21.44[7.93-58.04] <0.0001 11 6.1% 2 0.3% 23.86 [5.22-109.2] <0.0001
Bed-shared next to adult 19 8.6% 5 0.7% 19.35 [7.05-53.11] <0.0001 10 5.6% 7 1.0% 6.38 [2.38-17.12] 0.0002
(>2 units of alcohol)
Bed-shared next to adult 47 21.3% 26 3.9% 8.93 [5.27-15.14] <0.0001 12 6.7% 37 5.2% 1.42 [0.72-2.79] 0.32
who smoked
Bed-shared in the absence 23 10.4% 70 10.4% 1.62 [0.96-2.73] 0.07 1 0.6% 61 8.5% 0.08 [0.01-0.52] 0.009
of these hazards
*
Adjusted for infant age and whether a day or night sleep.
66 P. Fleming et al. / Paediatric Respiratory Reviews 16 (2015) 62–67

routinely, occasionally or never – on a number of outcomes during WHAT ADVICE SHOULD WE GIVE TO PARENTS CONCERNING
early childhood, using the technique of latent class analysis [28]. BEDSHARING AND THE RISK OF SIDS?
In this study the latent class analysis identified four distinct
groups; those who never bed-shared, a small group who always It is clear that, for parents who smoke tobacco, drink alcohol or
bed-shared throughout infancy and two groups we wanted to take recreational drugs, the risk of SIDS is significantly higher if
focus on to untangle the relationship between bed-sharing and they bedshare with their infant, especially if the infant was of low
breastfeeding: those who routinely bedshared from early infancy, birthweight or born prematurely, and the risk is even higher for
and those who did not bedshare in early infancy but did so from parents who fall asleep with their infants on a sofa.
late infancy/early childhood. For mothers who breastfeed, do not smoke or drink alcohol, and
Interestingly the socioeconomic characteristics of early bed- do not use recreational drugs the evidence of an increased risk
sharers - with a high proportion of breast fed infants, better from bedsharing is very limited.
educated, less socioeconomically deprived families, and lower There are no reported case control studies in which data on
prevalence of maternal smoking meant that this was a group in smoking, alcohol intake and drug use were collected that have
which the risk of SIDS was extremely low. This study, in which all shown any significant increase in the risk of SIDS associated with
infants survived infancy, confirmed the observation that mothers bedsharing in the absence of these known risk factors. Although
were more likely to bedshare with a male than with a female infant the Carpenter study purported to show such a risk, the use of
[28]. imputed values derived from studies in different populations in
We showed a strong, bidirectional relationship between order to compensate for the lack of such data from whole studies
bedsharing and breastfeeding throughout the first year of life, is in question. What is recognised, even in this debated paper, is
with those infants who routinely bedshared in early infancy having that the associations between bedsharing and SIDS risk vary
a higher prevalence and longer duration of breastfeeding, and greatly depending on the circumstances under which bedsharing
breastfeeding being maintained for longer amongst those infants occurs, lending further weight to the argument that any overall
who began bed-sharing later in infancy than amongst those who attempted ‘ban’ on such behaviour is inappropriate due to the
continued not to bedshare. variation within such practices. In the UK, our national advice
to parents to date has not been specifically to avoid bedsharing,
but rather to be aware of the factors that may put infants at
WHAT HAPPENED TO BEDSHARING DEATHS IN THE ‘‘BACK TO increased risk when bedsharing – notably parental alcohol, drug,
SLEEP’’ CAMPAIGN, AND WHAT EVIDENCE DO WE HAVE THAT tobacco use and the use of sofas.
AVOIDING BEDSHARING WILL PREVENT SIDS? Whilst no studies have shown that bedsharing has a protective
effect for young infants, the clear benefits associated with
The UK ‘‘Back to Sleep’’ campaign did not include any advice successful breastfeeding are such that it is important to facilitate
about bedsharing, and was followed by a dramatic fall in breastfeeding, which includes giving mothers advice on how to
numbers of SIDS deaths and in post-neonatal mortality (see safely feed their infant during the night time hours. Even if mothers
Fig. 2). Although the proportion of bedsharing deaths has do not intend to bedshare with their baby, breastfeeding at night
been reported to have risen since the ‘‘Back to sleep’’ campaigns is very tiring and mothers will inevitably fall asleep at times
of the early 1990s in many countries, the longitudinal study when feeding. Thus it is important to ensure that night time
from Avon [22] showed that the numbers of such deaths fell breastfeeding takes place in an environment that is as safe as
significantly, the rise in proportion of bedsharing deaths being possible. This, combined with evidence of an unaccustomed
attributable to an 80% fall in deaths of infants sleeping in cots sleeping environment as a potential risk [3,14–16] suggests that
with only a 50% fall in such deaths whilst bedsharing. This the most inherently sensible and ‘real world’ position to take on
difference in effect of the campaign may reflect the fact that the issue would be to openly discuss making all infant sleep
relatively few of the infants who bedshared before the ‘‘Back to environments as safe as possible, including adult beds.
sleep’’ campaign were sleeping prone, compared with those The ‘‘Caring for your baby at night’’ leaflet produced by UNICEF
sleeping in cots [22]. UK provides mothers with information on how to ensure the
Studies on the prevalence of bedsharing in the population of environment in which they breastfeed their baby at night is as safe
parents with young infants have shown different proportions in as possible, and allows parents to make informed choices about
different populations. As noted above, data collected as part of where and how to put their infant to sleep at night [30].
the ALSPAC study in the early 1990s showed, that mothers For parents who smoke, those who have been drinking alcohol
who were most likely to bedshare soon after their baby was or taking recreational drugs, or for parents of preterm infants it is
born were more likely to breastfeed, less likely to smoke, and clear that the increased risk of unexpected infant death attached to
were of higher educational levels and socioeconomic status sharing a sleep surface with their baby is significant, and this
than those who did not bedshare. In this group the risk of SIDS practice should be discouraged.
is very low. For mothers who wish to breastfeed, do not smoke, do not
Studies in UK families of South Asian origin - in whom smoking take recreational drugs or drink alcohol, and are aware of the
and alcohol use amongst mothers is very low have consistently importance of maintaining a safe sleep environment around
shown very high prevalence of bedsharing but extremely low rates their baby at night [30], there is no good evidence that choosing
of SIDS [29]. to share their bed with their baby puts the baby at increased risk
In contrast, studies amongst New Zealand Maori, Australian of unexpected death. The risk of bedsharing for such mothers
Aboriginal and Native American families where SIDS rates are high and babies is minimal, and the positive effect on breastfeeding
have shown high prevalence of bedsharing, but also high levels of rates for such mother-baby pairs may be an important long-
smoking and alcohol intake [1,7,14]. term benefit.
To date, no published intervention studies have shown that
reducing the prevalence of bedsharing reduces the SIDS rate. In our FUTURE DIRECTIONS FOR RESEARCH IN SIDS EPIDEMIOLOGY
studies we identified a number of instances of mothers who had
been advised not to take their baby into bed and chose to feed  Understanding the complex relationships between the various
the baby on a sofa where they fell asleep, and the baby died. known risk factors for SIDS.
P. Fleming et al. / Paediatric Respiratory Reviews 16 (2015) 62–67 67

 Identifying infants at biologically increased risk of SIDS and the death syndrome: results from 1993-5 case-control study for confidential
inquiry into stillbirths and deaths in infancy. BMJ 1996;313:191–5.
effects of epidemiological risk factors in such infants. [14] Scragg R, Mitchell EA, Taylor BJ, Stewart AW, Ford RP, Thompson JM, et al.
 Identifying the lowest risk strategies to facilitate breastfeeding Bed sharing, smoking and alcohol in the sudden infant death syndrome.
whilst minimising the risk of SIDS. New Zealand cot death study Group. BMJ 1993;307:1312–8.
[15] Tappin D, Ecob R, Brooke H. bedsharing, roomsharing and sudden infant death
syndrome in Scotland: a case-control study. J Pediatr 2005;147:32–7.
[16] Vennemann MM, Findeisen M, Butterfass-Bahloul T, Jorch G, Brinkmann B,
References Kopcke W, et al. Modifiable risk factors for SIDS in Germany: results of GeSID.
Acta Pediatrica 2005;94:655–60.
[1] Mitchell EA, Taylor BJ, Ford RP, Stewart AW, Becroft DM, Thompson JM, et al. [17] Carpenter R, McGarvey C, Mitchell E, Tappin D, Vennamann MM, Smuk M,
Four modifiable and other major risk factors for cot death: the New Zealand Carpenter JR. Bed sharing when parents do not smoke: is there a risk of SIDS?
study. J Paediatr Child Health 1992;28(Supppl. 1):53–8. An individual level analysis of five major case–control studies. BMJ Open 2013;
[2] Blair PS, Fleming PJ, Smith IJ, Ward Platt M, Young J, Nadin P, Berry PJ, Golding J, 3:e002299.
the CESDI SUDI research group. Babies sleeping with parents: case-control [18] Renz-Polster, De Bock F. More questions than answers. BMJ Open published
study of factors influencing the risk of sudden infant death syndrome. online June 10 2013.
BMJ December 1999;319:1457–62. [19] Blair PS, Fleming PJ, Ashmore S. A lack of data and questionable emphasis.
[3] McGarvey C, McDonald M, Hamilton K, O’Regan M, Matthews T. An 8 year BMJ Open published online May 22, 2013.
study of risk factors for SIDS: bed-sharing versus non-bed-sharing. Arch Dis [20] Russell CK, Ball H. Bed-sharing when parents do not smoke: is there a risk?
Child 2006;91:318–23. BMJ Open published online May 23,2013.
[4] Arnestad M, Anderson M, Vege A, Rognum TO. Changes in the epidemiology of [21] Blair PS, Sidebotham P, Pease A, Fleming PJ. Bedsharing in the absence of
sudden infant death syndrome in southeast Norway, 1984-1998: implications hazardous circumstances: Is there a risk of sudden infant death syndrome? An
for future prevention and research. ArchDis Child 2001;85:108–15. analysis from two case-control studies conducted in the UK. PLOS One 2014;9:
[5] Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, e107799.
Fleming P. Hazardous cosleeping environments and risk factors amenable to [22] Blair PS, Sidebotham P, Berry PJ, Evans M, Fleming PJ. Major changes in
change: case-control study of SIDS in south west England. BMJ 2009;339: b3666. the epidemiology of Sudden Infant Death Syndrome: a 20 year population
[6] Brooke H, Gibson A, Tappin D, Brown H. Case-control study of sudden infant based study of all unexpected deaths in infancy. Lancet 2006;367(9507):
death syndrome in Scotland 1992-5. BMJ 1997;314:1516–20. 314–9.
[7] Hauck FR, Herman SM, Donovan M, et al. Sleep environment and the risk of [23] Blair PS, Ball HL. The prevalence and characteristics associated with parent-
sudden infant death syndrome in an urban population: the Chicago Infant infant bed-sharing in England. Arch Dis Child 2004;89(12):1106–10.
Mortality Study. Pediatrics 2003;111:1207–14. [24] McCoy RC, Hunt CE, Lesko SM, et al. Frequency of bed sharing and its
[8] Klonoff-Cohen H, Edelstein SL. Bedsharing and the sudden infant death relationship to breastfeeding. Dev Behav Pediatr 2004;25(3):141–9.
stndrome. BMJ 1995;311:1269–72. [25] Santos IS, Mota DM, Matijasevitch A, Barros AJD, Barros FCF. Bed-sharing at
[9] Li DK, Willinger M, Petitti DB, Odouli R, Liu L, Hoffman HJ. Use of a dummy 3 months and breast-feeding at 1 year in Southern Brazil. J Pediatrics 2009;
(pacifier) during sleep and risk of sudden infant death syndrome (SIDS): 155(4):505–9.
population-based case-control study. BMJ 2006;332:18–22. [26] McKenna JJ, Mosko SS, Richard CA. Bedsharing promotes breastfeeding. Pedi-
[10] Tappin D, Brooke H, Ecob R, Gibson A. Used infant mattresses and sudden atrics 1997;100(2):214–9.
infant death syndrome in Scotland: case-control study. BMJ 2002;325(7371): [27] Chen A, Rogan WJ. Breastfeeding and the risk of post neonatal death in the
1007. United States. Pediatrics 2004;113:e435–9.
[11] Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Saueerland C, Mitchell [28] Blair PS, Heron J, Fleming PJ. Relationship between bed sharing and
EA. Sleep environment risk factors for sudden infant death SYNDROME: THE breastfeeding: longitudinal, population-based analysis. Pediatrics 2010;126:
German Sudden infant Death Study. Pediatrics 2009;123:1162–70. e1119–26.
[12] Vennemann MM, Hense HW, Bajanowski T, Blair PS, Complojer C, Moon R, [29] Davies DP, Gantley M. Ethnicity and the aetiology of sudden infant death
Kiechl-Kohlendorfer U. Bed sharing and the risk of sudden infant death syndrome. Arch Dis Child 1994;70(4):349–53.
syndrome: Can we resolve the debate? J Pediatr 2012;160:44–8. [30] Caring for your baby at night. Parental advice leaflet and health professional
[13] Fleming PJ, Blair PS, Bacon C, Bensley D, Smith I, Taylor E, Golding J, Berry J, guidelines can be found at: http://www.unicef.org.uk/BabyFriendly/
Tripp J. Environment of infants during sleep and risk of the sudden infant Resources/Resources-for-parents/Caring-for-your-baby-at-night/.