ARTICLE IN PRESS

Sleep Medicine Reviews (2006) 10, 407–417

www.elsevier.com/locate/smrv

CLINICAL REVIEW

Co-sleeping, an ancient practice: issues of the past

and present, and possibilities for the future
Evelyn B. Thoman

Department of Psychology, University of Connecticut, Storrs, CT, USA

KEYWORDS Summary Co-sleeping—infants sharing the mother’s sleep space—has prevailed

Co-sleeping; throughout human evolution, and continued over the centuries of western
Bed sharing; civilization despite controversy and blame of co-sleeping mothers for the deaths
Infants; of their infants. By the past century, ‘‘crib death’’ was recognized, later identified as
Sleep; Sudden Infant Death Syndrome (SIDS), and generally found to occur more frequently
Risks; during bed sharing. Pediatricians warned parents of the dangers of SIDS and other
Stress; risks of bed sharing, and the frequency of bed sharing decreased markedly over the
Sudden Infant Death years. However, during recent decades, bed sharing began to increase, though major
Syndrome (SIDS); issues were raised, including: whether bed sharing actually exacerbates or is
Crib death; protective against the occurrence of SIDS, whether the practice facilitates breast
Sleeping environ- feeding, whether bed sharing is beneficial for an infant’s development, and other
ment concerns. Dissention may soon be diminished by use of a crib which opens at the
mother’s bed-side and is becoming a popular approach to mother-and-infant
closeness through the night.
& 2006 Elsevier Ltd. All rights reserved.

Introduction many aspects of human behavior: as the nomadic

Throughout most of human existence, mothers and
their infants have shared the same sleeping
space—with close physical contact, she could
provide the infant with needed warmth and
nutrition, as well as protection from predators.
Thus, the practice referred to as ‘‘co-sleeping’’ was
essential to an infant’s survival.
However, during the most recent millennia,
change—the essence of evolution—occurred in
4324 170th Pl SE, Issaquah, WA 98027. Tel.: +1 425 378 1998;
fax: +1 425 378 2537.
E-mail address: evethoman@mac.com.
life was abandoned, different environments and
climates were adapted to, permanent dwellings
were built, and cribs of primitive types were made
for infants to sleep separately from their mother.1
Thus, co-sleeping became more a matter of choice
for the mother than a behavior pattern required for
the infant’s survival. However, from the time of co-
sleeping as an alternative practice, it became an
issue associated with turbulence and controversy
which persists to the present day.
The issues posed by co-sleeping (in recent years
referred to as ‘‘bed sharing’’) as an optional
practice have changed over time; and these
changes are considered as the context for

1087-0792/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.smrv.2005.12.001
 ARTICLE IN PRESS
408
emergence of more recent—and still disparate—
views. However, change has been greatest during
the last century, especially the later decades as a
vast amount of research on the hazards and
potential benefits of co-sleeping has been produced
around the world. The issues have been confounded
by recognition of the Sudden Infant Death Syn-
drome (SIDS) phenomenon, which may or may not
occur during co-sleeping. Accordingly, the history
of the major issues regarding co-sleeping will be
addressed, including reasons for this sleeping
pattern being abandoned by many—and the begin-
nings of a resurgence during the past century.
Co-sleeping in the Western world before
the 20th century
From the first century BC, Egyptian mothers who
slept with their infants were held responsible if
they died, as the mother was considered guilty of
intentionally smothering the infant. In the 1200s in
Germany, mothers were forbidden to take an infant
under 3 years into their bed at night. Over
subsequent centuries, mothers in various areas of
the industrialized world were punished if their
infants died while sleeping with them, and laws
were passed forbidding parents to let their infant
sleep in the family bed. Such suspicions prevailed
throughout the western world; and the association
of infant death and bed sharing became the context
for centuries of dissention.2
Mother blaming continued through the centuries
even though it ultimately became apparent that
some infants would die for no apparent reason
while sleeping alone in a crib. In fact, ‘‘cot death,’’
the term that was originally referred to rather than
‘‘crib death,’’ was attributed to the mother never-
theless. Not until the 1800s was it suggested that
‘‘crib death’’ might be the result of natural causes.
At one point enlarged thymus was proposed as the
precipitating factor. However, near the end of the
century, this theory was first questioned, then
discounted and abandoned.3
During this early era, in America as well as in the
European countries, objections to co-sleeping took
other expressions. It was even argued by many that
co-sleeping would lead to inappropriate sexual
thoughts or activity, would cause later sleep
problems, would interfere with parental sex, and
that it would be a difficult habit for the child to
give up as she/he grew older.2 Nevertheless, co-
sleeping has persisted to the present time, either
by choice or by necessity, in terms of available
living space—and more recently referred to as
‘‘bed sharing.’’
E.B. Thoman
Practice points
(1) In the industrialized areas of the world,
with permanent dwellings and cribs made
available, bed sharing ceased to be a
requisite for an infant’s survival.
(2) The practice of co-sleeping became a
source of controversy, with mothers being
blamed for the death of their infant if it
occurred while co-sleeping.
Bed sharing in non-industrialized
societies during the 20th century
The term ‘‘bed sharing’’ came to replace ‘‘co-
sleeping’’ because it is seen as more specific to
mothers sharing their sleeping space with their
infant.
The question of bed sharing has been addressed
during the past century from cross-cultural anthro-
pological studies. These have made available data
on many aspects of different cultures, such as the
physical environment, social and family structure,
and eating and sleeping practices.
From a study of 27 societies, it was found that in
24 of the cultures, infants slept with the mother
and possibly other members of the family, with only
three cultures in which the infants did not bed
share.4 A study derived from the Human Relations
Area files also provided data on many aspects of
living, including sleeping arrangements in 186 non-
industrial societies around the world. Of the 114
cultures with sleep information, in 72 cultures
infants more often shared the sleeping space with
their mother while in 42, infants more often slept
in the same room but not with the mother.5
These reports highlight the case that, by the
latest century, even in non-industrial societies,
while most mothers chose to share their sleeping
space with their infant, sleeping apart was the
chosen practice by many.
Bed sharing in the 20th century in
industrial societies
Cultural changes seem to occur at a more rapid
pace over time, and sleeping practices during the
20th century are no exception to this general-
ization. During the first quarter of the 1900s,
 ARTICLE IN PRESS
Co-sleeping/bed sharing
bed sharing with the mother and possibly other
members of the family was common, sometimes in
very large beds designed for the family. Exceptions
were mainly seen in the upper strata of society,
composed of those living in houses with more than a
single room. Over time, cribs rapidly began to take
the place of the family bed—and parents were
encouraged to use them as a way of helping their
infants develop independence. Accordingly, bed
sharing decreased dramatically, especially in this
country.3
During this era in America, breast-feeding came
to be replaced by bottle-feeding. Thus, another
imperative for bed sharing was abandoned—for a
time. Over the decades of the last century,
emphasis on breast feeding and bottle–feeding
has alternated, and with it views on greater
benefits of one mode or the other, with strong
proponents of each view. Numerous studies have
found that breast-feeding mothers are more likely
to bed share with their infant.
Throughout the last century, pediatricians have
urged parents to avoid bed sharing for safety
reasons, while some clinicians, researchers, and
authors writing on child care practices have
expressed concern for infants sleeping ‘‘alone in a
crib,’’ without the touch and smell of the mother or
opportunities for immediate and frequent breast
feeding. The strongest objection has been to
infants sleeping in a separate room from the
parents, in a ‘‘baby room.’’ However, there are no
data on the latter numbers during the early part of
the past century.
At least since the 1940s, mothers in this country
have generally been noted to use a bassinet or a
carriage for their infant to sleep in, so the baby can
be adjacent to the mother’s bed for her conve-
nience in breast-feeding throughout the night. A
carriage can serve double duty by being at the
bedside at night and moved with the mother to
other rooms in the house during the day, so the
mother can watch over the infant and be available
for interaction or feeding when he or she awakens.
By 3 months, most infants ‘‘graduate’’ to a crib,
placed either in the parents’ room or a ‘‘baby room.’’
This sleep pattern has been seen in most American
homes over the past century; in fact, it has been
readily apparent that many, maybe most, families do
not have living space to accommodate a separate
baby room, especially after the first child is born.
Practice points
(1) For many years, over the last century,
infants in this country have slept in the
409
same room with the parents during the
early postnatal months.
(2) Bed sharing diminished markedly; and
babies generally sleep solitary but in the
parents’ room during the early postnatal
months.
(3) It is apparent that ‘‘sleeping alone’’ has
not been as stark an experience as it has
been depicted in much of the popular
literature.
(4) At the same time, mothers have received
conflicting messages, namely, that they
‘‘should’’ sleep with their baby and that it
is dangerous to sleep with the baby.
Issues of concern for bed sharing and crib
death
At about the middle of the recent century, the issue
of infant crib death was joined with that of bed
sharing.
In California, in response to parents’ concern for
the perceived high death rate among infants, Child
Fatality Review Boards were formed with the
objective of determining factors related to infant
mortality; and such teams were then organized
throughout the country. The objective was to
identify causes of infant deaths, with the hope of
developing prevention strategies.6
The frequent finding from these efforts was that
infant deaths while bed sharing formed a large
percentage of those that could not be explained. As
these findings became widely known, they put a
pall on the notion of the value of bed sharing; and
crib use became ever more common.
While some mothers continued to bed share,
when an infant died while sleeping with the
mother, she was at times blamed for ‘‘laying over’’
her infant. This picture has been somewhat con-
founded over the years by a very small number of
mothers who were found guilty of smothering their
infant, but there were also some who were found to
have been erroneously convicted of infanticide.7,8
In time it became generally recognized that
‘‘crib death’’ could occur without obvious rea-
son—when the infant was sleeping in a crib or
during bed sharing. In response to continued
pressure from parents, a focus on the cause, or
causes, of infant crib deaths became a major
concern.
At an international conference in 1963, a number
of possible mechanisms were proposed for
these seemingly unexplainable deaths. At a later
 ARTICLE IN PRESS
410
international conference, the term SIDS was
adopted, defined as: ‘‘the sudden death of an
infant under 1 year of age which remains unex-
plained after a thorough case investigation, includ-
ing performance of a complete autopsy,
examination of the death scene, and review of
the clinical history’’.9, p. 681 Thus, SIDS was, and
still is, in essence, defined by exclusion—elimina-
tion of identifiable causes.
The exclusion aspect of the definition of SIDS is of
special significance for infants who have died while
bed sharing. Under these circumstances, forensic
pathologists became proponents of the importance
of examination of the scene of the death as well as
postmortem examination of the infant with the
objective of distinguishing SIDS from other causes,
including: accidental asphyxiation from laying over
by the mother while sharing the bed; becoming
wedged and strangled in some part of the structure
of the parental bed, including soft pillows or furry
objects over the infant’s face; or by hyperthermia,
either in or out of the mother’s bed.10 The
argument was also made for toxicological analysis
to supplement the postmortem examination.11
There continues to be a lack of consistency in
SIDS diagnosis. The distinction that continues to
elude pathologists is that between SIDS and
asphyxia due to the mother’s laying over the infant
during bed sharing.
Practice point
The same factors that constitute risk for SIDS
during solitary sleeping are found to be risk
factors for bed sharing, but with additional
hazards when sharing the parents’ bed.
Avoidable risk factors found to be
associated with bed sharing
While cribs are currently designed to meet safety
standards for infants, adult beds are designed for
adult needs and comfort. In addition to the risks
already noted, others remain an ongoing possibility,
including laying over by a parent or anyone else
who may be sharing the bed.10
In a 3-year study in England of 325 infants under 4
months who died unexpectedly and 1300 controls,
factors that were found to place infants at risk
when bed sharing included: an infant sharing the
parents’ bed for the whole night; smoking by the
parent; mother being excessively tired, or being
under the influence of drugs or alcohol; and finally,
E.B. Thoman
sleeping on a sofa with a parent, the family living in
overcrowded housing conditions.12
Bed sharing with other children was found to be
5.4 times more likely to have resulted in death than
occurred in a comparison control group of infants
sleeping solitary in a crib. In this study, an infant
sleeping on a sofa alone or with the mother was
also found to be a significant risk factor for infant
death.12
Difficult questions have been addressed from
research demonstrating these and other modifiable
risks associated with bed sharing. Maternal smoking
has been frequently reported to be a risk factor for
SIDS, and the risk is greater for bed sharing
infants.13
The relationship between SIDS and bed sharing
generally shows an increased association if the
parents are younger or if the parents are over-
weight.14
Hyperthermia has also been consistently found to
be a risk for SIDS, and the risk is greater when bed
sharing.15 These conclusions are consistent with
numerous reports that increased temperature of
infants is observed during bed sharing when
compared to solitary sleeping infants. More speci-
fically, the mean rectal temperature of bed sharing
infants over the night was reported to be 0.1 1C
higher than that of infants sleeping alone. In view
of the very small variance in rectal temperature at
this age, it is suggested that this differential
probably reflects a meaningful physiological differ-
ence between the two groups.16
Within this country, sociodemographic differ-
ences are found to make for differences in risks
associated with bed sharing. A study of African
American families compared with Anglo Americans
indicated that, for the former group, water beds
were more often used; comforters and pillows were
more often placed beneath bed sharing infants; and
bed sharing infants were more likely to habitually
be placed prone for sleep. These practices should
be expected to contribute to the higher risk
of bed sharing found among African American
families.17,18
A significantly greater probability of practicing
bed sharing is found in families with the following
characteristics: mothers less than 18 years old;
non-Caucasian parents; household income less than
$20,000; and living in a Southern state; African
American mothers were four times more likely to
bed share than white mothers; and Asian/other
mothers were almost three times more likely to bed
share than whites.19
Patterns of bed sharing vary among individuals as
well as ethnic groups, cultures, and countries.
Accordingly, studies may differ with respect to
 ARTICLE IN PRESS
Co-sleeping/bed sharing
criteria used for defining bed sharing, and the
results of any one study, therefore, might have
limited generalization. However, most of the risk
factors cited have been repeatedly studied by
means of longitudinal, large sample size, case
control studies and have been repeatedly found
across cultures and groups within cultures.
Practice points
(1) Based on the research findings, a number
of risk conditions are associated with
infant death during bed sharing—most of
which are culturally determined.
(2) The general conclusion arrived at by
researchers is that there is no basis for
encouraging bed sharing as a strategy to
reduce infant death.
Opposing views: the benefits of bed
sharing
Despite growing evidence for risks associated with
bed sharing, advocates of this sleep practice hold
the view that bed sharing is the most ‘‘natural’’
form of sleep-and-care giving because of its long
history as a behavior of the human species. Thus, it
is suggested that the infant is physiologically
designed for the conditions of this form of
mother-infant interaction.20 However, a contrary
view has been articulated: ‘‘It is as specious to
argue that the practice of co-sleeping is entirely
legitimized by its widespread presence across
cultures and centuries yas it is to imply that the
practice uniformly breeds y childhood insomnia or
impedes the development of separation-individua-
tion and autonomy’’.21, p. 255
Fortunately, these opposing views have been
addressed during the most recent decades from
intensive, rigorous research on the consequences
and correlates of bed sharing. Prospective multi-
center, longitudinal case control studies have been
carried out aimed at identifying ways in which bed
sharing may facilitate or pose a risk for infant
survival and development.
Such research is of critical note because the care
giving practice of bed sharing is currently increas-
ing. From 1993 to 2000 the percent of infants
sharing an adult bed at night increased from a low
of 5.5% to 12.8%, as already noted.19 A caveat for
that study, and others, might be the variation in
frequency and portion of the night that infants
may have bed-shared. However, wherever possible,
411
researchers have typically dealt with this source of
variability in their studies by enrolling as subjects
those who routinely share the mother’s bed most of
the night.
Advocates of bed sharing have proposed that bed
sharing is a care giving practice that is beneficial
for infants in three important ways: (1) sharing the
mother’s bed facilitates breast feeding and the
mother’s intimacy with the infant; (2) bed sharing
reduces the risk of SIDS; and (3) bed sharing may
facilitate the infant’s development. The following
is a review of findings with respect to each of these
expectations or assumptions.
Does bed sharing facilitate breast-feeding?
The notion that bed sharing facilitates breast-
feeding is a generally held proposition; and it would
seem to be affirmed, as a number of studies report
that there is a higher probability of mothers breast-
feeding among those that bed-share than if the
infant sleeps alone. It is clearly apparent that
breast-feeding, especially when demand is inter-
mittent, is more easily accomplished when mother
and baby are in close physical contact. Accordingly
proponents of bed sharing propose that the
practice contributes not only to more, but also
longer periods of breast feeding.22
However, an empirical demonstration of this
relationship as a causal one is not to be found—nor
is such a test feasible. Mothers who bed share are
self-selected, and mothers who choose bed sharing
are more typically those who are enthusiastic about
breast-feeding. So, only an association between the
two behavior patterns is demonstrable. Thus,
regarding this relationship, we are left with the
view that ‘‘It is obvious’’ that breast feeding is
facilitated by bed sharing.
The results of a recent study indicated that
breast-fed infants have lower rates of morbidity,
especially from infectious disease.23 Thus, it was
concluded that breast feeding is a protective
practice. However, an interesting point has been
raised, namely that the effects of the infant
receiving breast milk and the experience of breast
feeding cannot be separated, nor can the con-
sequences of breast feeding be separated from the
nature of the mother-infant relationship.24
Breast feeding during bed sharing has been
argued to be beneficial to the infant physiologi-
cally. Thus, the practice during bed sharing might
lead to an expectation regarding infants’ weight
change. In a study designed to address this
question, no significant difference was found
between bed sharing and crib-sleeping groups of
 ARTICLE IN PRESS
412 E.B. Thoman

infants. Postnatal weight loss was 6.3% for each positive nor negative consequences for bed sharing
group; and time to regain birth weight was 5.3 days children at any age.32
for crib-sleeping infants and 5.4 days for bed However, it should seem reasonable to expect
sharing infants. The results suggest that bed differential outcome as a function of the popula-
sharing, and accompanying breast feeding, does tion and context in which bed sharing is observed.
not play a distinctive role in determining weight In a small study to address this issue, 204 infants
change over the first year.25 (175 who were solitary sleepers and 29 that
routinely shared the parents’ bed), temperament
Does bed sharing protect the infant against was assessed at 4 months. The solitary sleeping
infants were characterized by more positive mood,
SIDS?
while the bed sharing infants showed more negative
mood.33
The possibility that bed sharing may serve to
A major source of variance concerns mothers’
protect infants against SIDS has long been a
differing motives for bed sharing: limited space,
question of interest. It has been argued that since
the infant being irritable or ill, the infant being
breast feeding is associated with reduced SIDS, and
wakeful for prolonged periods, the infant seeking
more breast feeding is associated with bed sharing,
frequent feedings, the mother preferring the ease
that bed sharing should be protective against
of breast feeding when her infant is close by, or the
SIDS.26 Evidence for the expectation of SIDS
mother considering bed sharing as the most
protection is supported by a New Zeeland, multi-
‘‘natural’’ way to breast feed her infant throughout
center case-control study which found that breast
the night. The nature and quality of their relation-
feeding is associated with a lowered risk for SIDS.27
ship will also be influenced by the interaction of the
However, contrary to this finding, a 2-year popula-
mother’s emotional valence for bed sharing with
tion based case-control study of 195 babies who
her infant and the infant’s responses. It is, thus,
died of SIDS and 780 matched controls found no
reasonable to expect some differences in infants’
evidence for breast feeding as a protective factor.28
later development as a function of the nature of
In view of the available evidence, the American
the early sleeping experience.
Academy of Pediatrics, after a 1997 conference of
the Task Force on Infant Positioning and SIDS,
endorsed the position of the panel of experts, that Practice points
there is no epidemiologic evidence demonstrating
that bed sharing is protective against SIDS.29 (1) Each of the three proposed advantages of
bed sharing has been addressed by re-
Dose bed sharing have positive search studies, primarily from short-term
or laboratory studies; and the findings are
developmental consequences?
minimally supportive.
(2) The studies indicate that more mothers
With respect to the nature of developmental
breast feed if they also bed-share.
effects of bed sharing, negative or beneficial, there
(3) Some studies suggest bed sharing is pro-
has been much speculation without much re-
tective against SIDS; however, the prepon-
search.30 However, from the vast literature on the
derance of research indicates that bed
effects of early experience on later behavioral
sharing places an infant at greater risk for
development in humans and animals,31 it should
SIDS.
clearly be reasonable to expect differences in
physiological, socio-emotional, and/or cognitive
development of infants as a function of the
differences in an early bed sharing or solitary
sleeping experience. Few studies have addressed
Sleep architecture as an indicator of
this issue. infant vulnerability for sids and
Long-term effects of bed sharing were investi- increased risk of bed sharing
gated from a prospective, 18-year longitudinal
study of Euro-Americans, initiated in 1974. Mothers Sleep patterns and risk for SIDS
were enrolled from the 3rd trimester of pregnancy.
Correlates of bed sharing were assessed, including Sleep architecture at every age is affected by, and
cognitive, social, emotional and developmental reflects, physiological and neurophysiological pro-
maturity; sleep problems; parental sexual con- ceses and the immune system of an individual.
cerns; even creativity. The results indicated neither Further, the basic significance of the sleep states
 ARTICLE IN PRESS
Co-sleeping/bed sharing
shown in early infancy is apparent in relationships
found between early sleep patterns and later
development.34 Researchers are giving growing
consideration to the possibility that some victims
of SIDS may have been vulnerable because of
central neural deviancy prior to the event. That
is, early postnatal (or even prenatal) neural
regulatory dysfunction may account for inadequate
arousal responsiveness in sleep, putting them at
higher risk. Accordingly, deviations from normal
sleep patterns have become of interest as possible
indices or antecedents of higher risk for SIDS.35,36
The strongest support for such an expectation is
found in studies that have investigated the sleep of
infants who later died of SIDS. Twelve-hour sleep
recordings made of twenty-two SIDS infants were
subsequently compared with recordings from 66
age-matched controls. The SIDS victims showed
fewer movements during REM sleep and less waking
than the control infants during the early morning
hours. These findings suggest a higher arousal
threshold in the SIDS infants and, thus, infants
who are less likely to arouse to a safer state in the
event of a vital physiological challenge.37
In a further study, infants who became victims of
SIDS a few days or weeks after being recorded were
compared with control infants matched for age.
Those who later died of SIDS showed more frequent
sub-cortical activation between 9:00 pm and mid-
night, and fewer cortical arousals between 3:00
and 6:00 am.38 Inference for the SIDS infants is not
so readily apparent from these findings.
Researchers have also investigated sleep archi-
tecture of infants considered to be at risk for
SIDS—‘‘at risk’’ referring to infants who were
siblings of SIDS victims. The sleep of such infant
and controls were compared at 1 week and 1, 2, 3,
4, and 6 months of age. The results indicated a
disturbed temporal sequencing of the sleep and
wake states throughout the age range of the
recordings.39
In a later study, researchers used the same design
to investigate differences in the sleep of siblings of
SIDS infants compared with controls. Again the
results indicated deviant sleep in SIDS siblings:
increased Quiet (delta) Sleep in the early morning
hours.40
Other studies have contributed to the literature
on deviancy in sleep architecture in infants who
succumb to—or are at risk for SIDS.41,42
Sleep patterns and risks of bed sharing
The risk of infants with inherent deviancy, as can be
indicated by their sleep architecture, may be
greater as a function of their sleeping environment.
413
A major sleep pattern of concern, greater
frequency of arousals (not necessarily complete
awakenings), has been generally found to charac-
terize infants when sleeping with the mother. This
pattern, identified as sleep fragmentation,38 is
associated with an increase in arousal threshold,
as might be expected.43 Sleep fragmentation is
found to be greater in early infancy and shows a
developmental course of decrease, especially over
the first year. Also because it is associated with less
Quiet Sleep, greater fragmentation is assumed to
be an expression of less maturity at any age.44,45
Further, sleep fragmentation/disruption is
viewed at all ages (i.e., even in adults) as an
expression of stress, as a consequence of the sleep
deprivation involved.41,46 That is, in early infancy,
when the stress causes sufficient sleep deprivation
and physiological fatigue, a failure to arouse and,
thus, to restore sufficient tone to respond to a
respiratory challenge may occur, and the infant
may become a victim of sudden infant death.41
For another investigation of the sleep of infants
who typically share and those who typically sleep
solitary, the sleep of the bed sharing infants
was recorded during nights or periods of the night
when sleeping alone—even bed sharing infants
sleep alone for considerable periods of time,
obviously because they sleep much more than their
mothers do.
For this study, non-intrusive recordings of the
infants’ sleep were made in the home.47,48 The
results indicated that the bed sharing infants, when
sleeping alone, showed fewer arousals, i.e., less
sleep fragmentation, with more and longer bouts of
Quiet Sleep than the solitary sleeping infants. This
is a contrasting pattern to the greater frequency of
arousals and diminished Quiet Sleep typical of
infants during the times when they are bed sharing,
as described above, or, as has often been de-
scribed, when infants have been deprived of
sleep.42,49 The sleep pattern exhibited during these
periods is clearly one of a higher arousal threshold,
with the suggestion that the infant is at a greater
risk for SIDS.47
These results suggest that solitary sleeping
periods of bed sharing infants are times when
infants are compensating for the sleep deprivation
experienced during bed sharing.
Practice points
(1) The findings from sleep studies indicate
that infants who become SIDS victims show
evidence of neural compromise prior to the
final event.
 ARTICLE IN PRESS
414 E.B. Thoman

(2) It has been concluded that neurobehavior- evidence that a number of hazards are associated
al deviance may be induced or exacer- with bed sharing. The findings might seem to argue
bated by the sleep disruption an infant overwhelmingly against the practice under all
experiences during bed sharing. circumstances.
Nevertheless, the position currently taken by
many child care providers is that bed sharing is a
reasonable option for parents who prefer to do so,
provided the sleeping environment is made safe for
Considerations for future research
the infant—even though the term ‘‘safe’’ remains a
complex qualifier, difficult to comply with.
Issues for future SIDS research
The question that persists is whether an infant is
at higher risk when bed sharing or bed sharing can
Much has been learned about SIDS, both when
be made safe enough to be developmentally
infants sleep in a crib and when they share the
beneficial for infants of parents who choose to
mother’s bed. However, there is still no reliable
bed share. And this question is even more serious
way to either predict or prevent SIDS, as the
when viewed within the perspective of the con-
cause(s) remain unknown.50 It is generally expected
sistent finding that in some infants, already
that, with continued research, the mechanism
immature control mechanisms may be aggravated
underlying SIDS will ultimately be defined and
by environmental factors; and these are more likely
described as a specific physiological event. And it
to be adverse for the infant when bed sharing.54
is currently concluded, from research findings, that
In large part, as a result of admonitions about
the physiological changes or deficits involve both
bed sharing, this child care practice reached a very
arousal responses and cardiac autonomic controls
low level by the middle of the past century. In
during sleep-wake processes.51,52 Further, it is now
recent decades in the United States, the trend has
more generally inferred that ‘‘the fatal event
reversed and bed sharing is on the increase as a
involves a neurally-compromised infant, circum-
routine practice. While there is a vast literature on
stances that challenge vital physiology, most likely
the risks of bed sharing, much less empirical data
during sleep, at a particular developmental
have been collected on possible benefits. Thus,
period’’.53, p. 123 From this perspective, research
there is the need for further research on this
continues to be aimed toward identifying SIDS as
practice—in order to identify both negative and
distinguished from other causes of infant death
positive, short-term and long-term developmental
during bed sharing.54
consequences.
Progress is destined to be made in view of the
intensive, ongoing research programs that are
focused on SIDS. As one instance, the San Diego Difficulties in disseminating research findings
SIDS Collaborative Research initiative (Henry F.
to health professionals and parents
Krous, Investigator) has the goal of collecting
consistent postmortem specimens along with clin-
While it is recognized that bed sharing can be made
ical, epidemiological and pathological data from
much safer, the challenge is even greater to ‘‘get
infants dying suddenly and unexpectedly. Sharing of
the message out’’ regarding the necessity for
data and materials from investigations by research
precautions with respect to risk factors and the
centers around the world are in progress and will
means by which they may be addressed. Obstacles
permit comparison of various functions and ab-
to devising successful programs include differences
normalities within the same infants dying of SIDS.
in bed sharing patterns as a function of variations in
This is one of over forty research projects funded
attitudes dictated by cultural, ethnic, regional, as
by the First Candle/SIDS Alliance over the past two
well as individual differences among mothers (or
decades.54
both parents).55 Research indicates persistence in
the bed sharing practice by some groups irrespec-
Future research on bed sharing tive of efforts that have been made to provide
information on risk factors.
Throughout the centuries of recorded history, co- Since the practice of bed sharing is currently
sleeping/bed sharing has been blamed, banned, increasing, an obviously meaningful goal of re-
praised and revered. The controversy over its search is to develop protocols that would serve
values and dangers persists to the present day, even more effectively for informing health care
even though recent decades have been a time of professionals and parents of the risks and benefits
intensive, rigorous research that has provided of bed sharing.55
 ARTICLE IN PRESS
Co-sleeping/bed sharing
The difficulties of education are made evident in
a report of the failure of parents to respond to a
publicity campaign in Ireland which was designed to
inform parents on means of reducing the risk of
sudden infant death. Afterward, 41 percent of
infants surveyed were still placed on their side to
sleep, over 60 percent were exposed to adult
smoking in the home, 68 percent were over-
wrapped at night, 13 percent regularly bed shared,
and 20 percent of those parents smoked.56 As an
instance, while reduction of prone sleeping ac-
counted for a major reduction in SIDS, it continues
to be a significant risk factor in primarily African
American groups—one third of the SIDS deaths
were noted to be attributed to this factor.
Obviously, the program or the methods of outreach
were not the most relevant for this group.56
The results of these studies highlight the need for
ever more flexible, individualized campaign pro-
grams for the specific groups of parents. As part of
such programs, it is recognized as requisite for
researchers to provide medical and other clinical
professionals with regular updating that will enable
them to instruct families on safe options with
respect to sleep environments for their infants, as
well as other care giving practices. From this
perspective, research continues to emphasize the
urgency of informing parents of the importance of
an appropriate thermal environment for their
infant, the potential risk of smoking, consumption
of alcohol or other substances that may impair the
arousal of adults during the night—as well as the
design and position of a family bed and other risks
of bed sharing that have been identified in
numerous studies.37,57–60
Bed sharing is practiced with a wide range of
behavioral arrangements. Thus, the issue remain-
s—how to find ways to communicate to diverse
cultures and individuals the rather extensive
modifications of bed sharing conditions that are
required to make the bed sharing scene ‘‘safe.’’
A shift in perspective on infants’ sleeping
environment
With respect to advice on an optimal sleep
environment for infants during the early postnatal
months, there is growing agreement that the
number of remedial risk factors that have been
well documented from extensive research argues
against bed sharing for most families.
A dramatic shift in perspective is ‘‘in the wind.’’
That is, even some of the most ardent advocates of
bed sharing among researchers, as well as others
415
writing for the popular media, have begun to
consider the possible desirability of infants sleeping
in a crib that is adjacent to the mother’s bed and
opens to her bedside. Thus, the design facilitates
the ‘‘closeness’’ that is so desirable to the mothers.
If this approach continues to receive attention and
achieve greater acceptance, the trend toward
increased bed sharing may diminish, with the
possibility of a remarkable decrease in infant
deaths from bed sharing.
Research agenda
Continued research on the physiological me-
chanisms accounting for SIDS, including those
that are antecedent to the final event, will be
requisite for distinguishing SIDS from other
causes of infant death during bed sharing. New
research strategies, as described, have con-
tinued to progress in this direction, especially
the very difficult approach of obtaining data
on infants prior to their becoming victims of
SIDS.61 In our view, another important ap-
proach is the naturalistic study of infants’
sleep and respiration patterns made possible
by recordings obtained non-intrusively in the
home.
Views on bed sharing, as a preferred
practice for some parents, must continue to
be informed by evidence from epidemiology,
physiology, and anthropology—if issues are to
be addressed by more than rationales for
strongly held opinions.61
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