If I had it to do over again, I would still bed-share with my babies

I adopted attachment parenting back in 1986, a few months after our first child was born. A few months before the birth would have been better. That’s why I sometimes envy today’s mothers, who know from the get-go that baby-wearing, sleep sharing, and breastfeeding on cue are viable choices.

On the other hand, parents today have to confront something that I did not: a drumbeat of warnings from the medical establishment that they are endangering their babies’ lives by allowing them in their bed.

Even in the absence of those warnings, it’s not that my husband and I came to bed-sharing easily. Someone had gifted us the 40th anniversary edition of Dr. Spock, and clearly babies spending the night in the parental bed was not something he approved of. He didn’t approve of too much daytime carrying either: “It isn’t necessary or sensible for [the baby] to be in a parent’s lap or arms or to have his father or mother amusing him much of the time.”

So it wasn’t from books we learned attachment parenting; it was from our daughter. She came into the world rosy and strong and pretty clear on what she needed. But we had a crib ready for her and a lot of expectations about babies spending a good deal of the day on their own. (See Dr. Spock, above.) There ensued a struggle. We were certainly not neglectful parents by the standards of the day, but there was a lot of crying going on and—in retrospect—a sort of continual tug-of-war, Elly always wanting to be held and us testing each day to see whether she had turned into that “independent” baby we imagined.

The worst problem, worse even than the long bouts of inconsolable colicky crying, was lack of sleep. It was nearly impossible to get Elly down into her crib without her waking and starting to scream—if not immediately then a very short while later. If we put her in the crib already awake the screaming began the moment she lost contact with us. Dr. Spock said that a half hour of crying would seem like forever, but if we set a timer we would see that it was only 30 minutes after all and that at the end of that time she would almost certainly have fallen asleep.

Not even close.

So we got by on snatches of sleep in the short intervals when we could actually lay her down without waking her. And then in the middle of one night something horrifying happened. Dazed by exhaustion, I failed to get the safety strap latched around her properly as she lay atop her dresser with the built-in changing pad. I took a step away to reach some garment draped over the side of the crib, and turned back just in time to catch her as she rolled off the side. She wasn’t old enough yet to accomplish a purposeful “roll-over,” but she could clearly lurch around with considerable strength.

We were living at the time in a housing project on the Navajo Nation, where my husband and I had gone to practice law. The floor was a hard concrete slab three-and-a-half feet below. I was convinced that Elly had almost died.

After that it no longer seemed worth braving sleep deprivation in order to uphold some notion of where babies should sleep, and we brought her into our bed. We worried at first about rolling over on her. But I realized that she was not too helpless to raise an alarm if someone started leaning on her, and it really was not too likely that we were going to land on her suddenly as is from a great height—any more than my husband and I were likely to fall out of bed or slug one another in our sleep.

Looking for reassurance, I would eventually find Dr. Sears’ early writings, and when we left the Reservation some months later I found La Leche League enormously supportive. Meanwhile I took some comfort in the example of the co-sleeping Navajo mothers around me, and even the Pakistani co-workers who had pushed the mattresses together in their bedroom to create a wall-to-wall bed for the family.

Our new arrangement allowed me enough sleep to function, definitely more than we had gotten before, but I still wouldn’t say we slept all that well. When baby Matthew arrived three years after his sister, he was in our bed from day one, and the adjustment went much more smoothly. This is not to say we slept through the night unbroken, but we achieved a synchronicity where we would both emerge from sleep together to nurse, and then drift off again.

Now, though, that a lot of parents have gotten past the old bugaboos about the psychological risks of bed-sharing, we have a host of new warnings that bed-sharing is dangerous, from organizations including the American Academy of Pediatrics. The experts would have us believe that my husband and I, waking every morning to find our children alive and well, had dodged a bullet. Or perhaps it was that we had dodged a knife – that being the implement shown lying next to a baby in a public service announcement run by health authorities in Milwaukee. The message was that if you wouldn’t allow your infant to sleep next to a cleaver, you shouldn’t allow him or her to sleep next to an adult either.

I am the kind of conscientious person who takes cautionary statistics and public health campaigns very seriously. But at some point in my life I realized that the fact [oops! turns out it’s a myth] that half of all marriages ended in divorce didn’t mean that mine faced fifty-fifty odds; I had inside information allowing me to make a more customized assessment of the situation. And when the state of Arizona phased in a requirement for hepatitis B vaccinations among middle-schoolers in 2000, it made no sense for us as a family to vaccinate our pre-teen son but not our teen-aged daughter, for all that that was the plan the bureaucrats were promoting.

It is precisely because the authorities (unfortunately) see it as their job to come up with one-size-fits-all prescriptions that making an informed decision to ignore their advice may be the most responsible thing a parent can do. For a long time the warnings against bed-sharing issued by the American Academy of Pediatrics were based on studies which folded into the statistics parents who smoked, parents who came to bed inebriated or otherwise incapacitated, and parents who spent the night with their babies on a couch. Parents who knew—as did my husband and I—that there was no chance they were going to fall into bed dead drunk a few weeks after initiating the bed-sharing habit would be justified in concluding that the research results had very little to do with them, regardless of what behavior the medical authorities might attribute to their audience.

In mid-2013, though, a journal article was published which re-analyzed older data and reached the conclusion that for infants under three months old, bed-sharing even under relatively safe conditions is correlated with an elevated risk of Sudden Infant Death Syndrome (SIDS). Elevated, that is, by comparison to what the AAP considers the gold standard of infant sleep—breastfed babies sleeping on their backs in cribs in their parents’ bedroom. (Formula-fed babies and babies sleeping in rooms apart from their parents show higher rates of SIDS—for all that there are no public service announcements depicting the Grim Reaper stalking the nursery.)

So had the research finally caught up to the recommendations, retroactively justifying the medical establishment’s warnings?

Not quite.

The methodology of these studies is extremely tricky to design, and there was at least one major pitfall which the 2013 analysis had failed to overcome. It didn’t distinguish between babies for whom the parental bed was their primary sleep location, and babies who were only occasionally in the parental bed.

Let me hasten to explain that the concern here has nothing to do with whether families who co-sleep only part of the time are somehow more awkward at it when they do. The problem is a statistical one which confounds the researchers’ attempts to sort out cause and effect.

In carrying out these “case-control” studies, the researchers look to see what percent of babies who died of SIDS were in the parental bed at the time, and then compare that to the rate of co-sleeping among similar “control” babies. If the proportion of co-sleepers was higher among the babies who succumbed, then the researchers conclude that the co-sleeping itself created some element of danger.

But what if the reason more of the SIDS babies were co-sleeping is that their parents sensed something wrong with them? That is, how do we know that there wasn’t some factor pertaining to the health of the baby which both increased the risk of SIDS and increased the probability that the parents would take the infant into the bed?

Something, after all, determines whether the infant in a flexible-sleeping-arrangement household is in the parental bed at any given moment. It would take only a small number of cases in which that something was an infant facing a health challenge to undermine the researchers’ conclusions. It wouldn’t even be necessary that the parents were consciously aware of the baby being ill; just that something about the baby’s behavior—fussiness, or difficulty settling—upped the likelihood that he or she would be taken into the parental bed.

The only way that I can see to avoid this methodological flaw would be to break out primary co-sleeping families, those in which the baby routinely spends the better part of every night in the parental bed.

There are indeed studies which talk about having analyzed “usual” or “routine” co-sleepers. But on further examination it turns out these researchers still weren’t looking at primary co-sleepers, but using far vaguer, even inconsistent, definitions of “routine.” Take for example a 2009 German study using one of the same databases—and with one of the same authors—as the 2013 meta-analysis. Of 333 AIDS cases, only 26 families responded “parental bed” when asked where their babies usually slept. Yet one table later, there are 146 SIDS cases classified as “usual” co-sleepers. It turns out this referred to infants who were reported to spend some interval co-sleeping either “sometimes” or “every night,” as opposed to “never.” In other words, the researchers had identified exactly the kind of flexibly-sleeping family whose infant was in the parental bed when there was some reason for him or her to be there. The fact that 27% of the infants who succumbed to SIDS in these “sometimes” bed-sharing families were in the parental bad at the time of death, while only 22% of the “sometimes” bed-sharing controls were in the parental bed during the last sleep inquired about, gave rise to the conclusion that even “usual” bed-sharers were endangered by being the parental bed.

What, though, about the 26 families who reported the parental bed as their infants’ primary sleep location? That group showed no increased risk of SIDS.

It remains a distinct possibility that for infants whose parents don’t drink, drug, or smoke, the family bed is the safest sleeping arrangement of them all.

The 27% vs. 22% comparison should give an idea that the differences the researchers are seeing between the groups they contrast are not large. In the 2013 meta-analysis, the authors set out to quantify for readers how much additional risk was being run by bed-sharing families. They indicated that in a typical situation, room-sharing babies laid on their backs in their cribs by non-smoking parents would be expected to succumb to SIDS in about 8 out of 100,000 cases, while for bed-sharing cases the number would rise to about 23 in 100,000.

But there turned out to be something a bit odd about that “typical.” The numbers provided assumed a baby born weighing between 2.5 kg (5 pounds 8 ounces) and 3.5 kg (7 pounds 11 ounces). This included the low end of normal birthweights, but lopped off the entire upper end.

At least one-third of babies weigh more than 7 pounds 11 ounces at birth and are at markedly decreased risk of SIDS no matter where they sleep. In fact among the control babies in the study who were supposed to represent the general population, fully half weighed over 3.5 kg at birth, calling into question whether the numbers the researchers chose to highlight really represented what was typical for their audience. A nice even one-kilogram range from 3.0 to 4.0 kg would have included far more babies.

My children having weighed more than the seven-pound-eleven-ounce cutoff at birth, I was curious to see what risk numbers the authors’ analysis would assign to them. I found my answer in an online appendix to the study. For “cohabiting white women age 30+ with 1st baby birth weight > 3500g,” the expected rate of SIDS for room-sharing infants was 11 out of a million, and for bed-sharing infants 31 out of a million. Put another way, my husband and I were theoretically running an additional risk of about 1 in 50,000 by bed-sharing.

That’s about the risk of dying while playing soccer – something we also allowed our children to do.

And if I had it to do over again, the only change I would make would be to start bed-sharing earlier, before I reached that point of exhaustion where I was a menace to my baby.


 

 

The studies analyzed in this post are:

2013 meta-analysis: Carpenter R, McGarvey C, Mitchell EA et al. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case-control studies. BMJ Open 2013;3:e002299.doi:10.1136/bmjopen-2012-002299

2009 German study: Vennemann MM, Bajanowski T, Brinkmann B et al. Sleep Environment Risk Factors for Sudden Infant Death Syndrome: The German Sudden Infant Death Syndrome Study. Pediatrics2009;123;1162.doi:10.1542/peds.2008-0505