A clinical report of adverse health effects due to bed sharing in two children with spinal cord injury and traumatic brain injury.

Abstract: This paper explores the possibility that bed sharing may carry particular risks for children with special healthcare needs (CSHCN). Two cases of CSHCN who may have sustained adverse health effects from bed sharing are described. These two case reports indicate that CSHCN may be particularly susceptible to risks associated with bed sharing. Healthcare providers for CSHCN may need to inquire about patients' sleeping arrangements and, when bed sharing is acknowledged, provide counseling regarding the potential risks and benefits. They may need to monitor more closely for adverse events when bed sharing is a factor and should consider reporting health problems that may have occurred in concurrence with bed sharing.

Key Words: disability, bed sharing, cosleeping, sleep, risk factors

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The issue of bed sharing or cosleeping involving adults and children has been an ongoing matter of debate in the medical literature in regards to both cultural practices and the potential risks and benefits associated with the practice. (1-7) Technically, "cosleeping" refers to multiple persons sleeping in the same environment, whether in the same bed or in the same room, while "bed sharing" specifically refers to two or more persons occupying the same sleeping structure (bed, mat, etc.). However, the literature frequently equates cosleeping and bed sharing. To date, debates as to whether bed sharing presents benefits or risks, and whether the possible benefits outweigh the potential risks, have not been resolved. In addition, the majority of the discussion has focused on children without special healthcare needs. The following case reports indicate the possibility that children with special healthcare needs (CSHCN) may be a subgroup that is at greater risk for potential adverse effects of bed sharing than "normalized" children

Case Reports

Case Report 1

A previously healthy 22-month-old female sustained multiple traumatic injuries, including traumatic brain injury and a thoracic level 2 (T2) spinal cord injury (SCI), resulting in complete paraplegia, with no sensation below the T2 dermatome area and with no volitional movement in the bilateral lower extremities.

Three months after the initial injury, the patient developed an elevated temperature to 39.1 [degrees]C. After obtaining blood and catheterized urine cultures, the patient was started on IM ceftriaxone. Urine culture subsequently showed more than 100,000 colonies per high-power field of Citrobacter diversus with only 6 white blood cells per high-power field in the urinalysis. Pre-antibiotic blood cultures X 2 had no growth. The next day, her temperature had returned to normal and examination revealed no swelling of the legs (the child had been specifically assessed for deep vein thrombosis, an increased risk in SCI patients). Early the next morning, she developed a temperature of 40.0 [degrees]C. Examination revealed a swollen left lower extremity. A white blood count showed only 9.6 X [10.sup.3]/[mm.sup.3] with a nonspecific differential, and a catheterized urine culture showed no growth. X-rays showed a transverse fracture through the distal shaft of the left femur involving the metaphysis without callus. The knee joint was aspirated with negative culture results and no evidence of significant white cell elevation. Duplex Doppler ultrasound showed no evidence of deep vein thrombosis. A one-phase, whole body technetium 99m-bone scan was performed and showed no evidence of heterotopic ossification. The radiologist believed that this was a new fracture, and review of x-rays made during her initial trauma evaluation did not show evidence of a fracture in the same area. The child had no active physical therapy since the onset of the first fever, and neither the hospital staff nor the patient's mother reported any traumatic event occurring during that period. The new, acute lower extremity swelling had not been noted on the two previous examinations.

This history is significant because the mother, who has a weight of 100 kg, often slept with the child in her hospital bed. She had been sleeping with her child during the night that the swelling and fever were noted on routine nursing check, which prompted the call to the physician for an examination. Although other possible sources of trauma--including falls, medication injection, procedures, and therapy--were investigated with the parent and the staff, none could be ascertained. The fracture did not exhibit the classic features for nonaccidental trauma, such as a spiral fracture or a chip fracture of the corner of the metaphysis, according to the radiologist. No emotional or behavioral disturbances had been noted on the mother's part. She indicated that she had been sleeping soundly in bed with the child. Nor was there any evidence before hospitalization, during hospitalization, or more than a year after discharge to suggest abusive behavior by the caregiver. Thus, fracture secondary to "overlay" is considered a strong possibility given the timing of occurrence. The child's high-level paraplegia and lack of any sensation in the lower extremities could have prevented the child from recognizing discomfort and hence crying out or trying to escape entrapment, which would have been further precluded by her motor limitations. Additional questions arose as to whether the child's second bout of fever was actually the result of the transfer of maternal body heat during bed sharing. With the discontinuation of bed sharing, the child's temperature quickly fell to normal and did not rise again.

Case Report 2

A previously healthy 2-year-old male sustained a severe traumatic brain injury and left subdural hematoma with secondary severely increased intracranial pressures. He subsequently developed hydrocephalus requiring ventricular-peritoneal shunting. Computed tomography head scans showed extensive encephalomalacia throughout the bilateral frontal, parietal, and occipital lobes and in the bilateral basal ganglia coupled with ex vacuo dilation of the ventricles. The patient also developed panhypopituitarism thought to be secondary to hypothalamic and/or pituitary injury, which required L-thyroxine replacement for hypothyroidism, desmopressin acetate for diabetes insipidus, and hydrocortisone replacement for hypo-adrenalism. He remained in a persistent vegetative state throughout his four months of hospitalization.

The child experienced ongoing difficulties with thermoregulation, which were thought to be secondary to his hypothalamic/pituitary injury. At times, he manifested temperatures down to 32.2 [degrees]C and, less frequently, periodic hyperthermia. These temperature elevations subsided during his last two months of admission. He was evaluated repeatedly for infections, but a specific infection was not found after the first two months of hospitalization. Although his hospital course generally stabilized, he experienced three further temperature elevations on three occasions during the last month of admission. On one occasion, a brief rise to 38.6 [degrees]C occurred after the child was provided a new, heavy wool sweater to wear overnight in addition to being covered with heavy blankets. Removing the sweater and blankets the next morning resulted in his temperature quickly returning to a normal level. The other two incidents of elevated temperatures--to 39.4 [degrees]C and then to 39.6 [degrees]C 4 days later--occurred during times that the child was sleeping in close contact with his mother; both were covered up thoroughly with standard hospital bed sheets. The mother had expressed a strong desire to be in close contact with the child for her emotional needs. Uncovering and discontinuation of bed sharing at night resulted in the child's temperature returning to normal within one to four hours on both occasions. The mother was advised to avoid sleeping in bed with the child overnight and instead to snuggle with her child when she was awake and without the use of coverings. Once these practices were initiated, the temperature elevations did not recur. These last two instances of temperature elevation were thought to have resulted from the phenomenon of body heat transference to a patient who was poikilothermic and therefore had limited ability to self-regulate body temperature. By changing sleeping patterns, coverings, and contact habits, the problem appeared to resolve and did not recur.

Discussion

The practice of infants and children sharing beds with adults varies greatly among and within countries, cultures, and socioeconomic groups. (1-5) The question of whether this practice is medically appropriate elicits strong opinions and convictions on both sides with debate focusing on both the medical benefits and risks as well as on issues of cultural practices. (5-7) The vast majority of surveys and reports on the benefits and risks of bed sharing have involved only "normalized" children, not CSHCN. Although the psychosocial effects of bed sharing have been investigated, (8-10) the majority of investigations have focused on physical risks, particularly in regards to sudden infant death syndrome (SIDS).

Multiple papers and editorial letters have produced conflicting results and opinions about whether bed sharing increases mortality and morbidity of SIDS or protects against SIDS in "normalized" children. (11-34) There has been a marked decline in the incidence of SIDS following the implementation of the recommendation to place infants in the supine sleeping position in regions where the practice has been followed by the majority of the population. (7,35) The American Academy of Pediatrics (36) finds no evidence that bed sharing protects against SIDS but acknowledges that crib sleeping in the caregiver's room for the first 6 months of life may be protective. (7)

Overheating has been raised as a possible factor in some SIDS cases. A certain number of children with SIDS have been found paradoxically to have core body temperatures above normal after death, raising questions about infection, febrile convulsions, overdressing, heavy covering, sleeping positions, location near external heating sources, and other factors that may lead or contribute to hyperthermic injury or heat stress. (37-40) Both lack of cognitive and motor ability in children to remove excess coverings or move away from external heat sources by themselves, as well as children's lesser ability to regulate body temperatures and recover from heat exposure have been postulated for children's higher risk of environmentally induced hyperthermia. (41-45) Children have higher surface-area-to-mass ratios than adults, resulting in greater heat absorption than experienced by adults. (41-45) Even when body size is compensated for, children's smaller blood volumes and smaller relative surface area may limit heat transfer from the body during heat exposure. (41-45) As yet, there appear to be no definitive studies of infant body temperature regulation in bed sharing situations.

The phenomenon of "overlay" has been raised as a particular risk associated with bed sharing in children without special needs. (18,27,32,34,47,50,53) Also, unsafe sleeping sites and devices may pose risks. (18,19,32,34,46-53) In a review of U.S. Consumer Product Safety Commission (CPSC) data from January 1990 to October 1997, Nakamura et al (50) found 515 deaths in children under age 2 who were sleeping in adult beds, and 121 of these deaths involved overlying by a sibling, parent, or other adult sharing the bed. In their review of Cleveland death certificates for 2,178 infants who died as a result of mechanical suffocation from 1982 to 1985, Carroll-Pankhurst and Mortimer (27) found that 180 cases were attributed to parental overlay.

In the ongoing discussions regarding benefits and risks of bed sharing for "normalized" children, the question arises as to whether there may be subcategories of children, such as CSHCN, for whom the benefits and risks may differ because of their special needs. In general, the availability of epidemiologic injury studies focusing on children with disabilities is limited. One of the difficulties is the lack of agreement on the definition and incidence of "disability." (54,55) Lack of standardized terminology, methodologies, or definitions for the etiologies and categories of patients to include in surveys complicates the assessment of rates and incidence of injuries in CSHCN.

A review of the available literature on injuries in CSHCN shows that bed sharing is not one of the subcategories usually investigated. Likewise, there does not appear to be any literature regarding the prevalence of bed sharing involving CSHCN. Gaebler-Spira and Thornton (56) and Pertridou et al (57) made no specific mention about injuries to CSHCN secondary to bed sharing. Only a few reports of sleeping injuries involving CSHCN are available other than those that concern prematurity (in association with SIDS), and these few cases involved children sleeping alone or suffering strangulation injuries secondary to adverse body positions in sleeping devices. (47,50-52) A CPSC study of children over age 2 sleeping in adult beds identified 17 deaths among these children, eight of whom were severely disabled. (50) Nakamura et al (50) speculated in this report that disabled children are more vulnerable "if their disability prevents them from freeing themselves from a compromising position, such as entrapment." Of a total of 52 cases of injury to children that occurred between January 1990 and March 2000, CPSC reported the deaths of 12 children--three of whom were disabled--as a result of sleeping-related injuries, specifically, strangulation in bed rails. (51) CPSC offered no comment about whether the nine children that were found to have suffered injury without death and the 31 children who were noted as incidence-without-injury were disabled.

All previously published articles on cosleeping injuries have been based on second-or third-hand reports from consumer agencies or public health records and death statistics. (12,13,19,27-29,32,34,46-52) The cases described in this paper appear to be the first to be reported that involve a more controlled observation environment under supervision of medical personnel.

Because ward personnel who investigated and treated these cases were unaware of bed sharing issues, detailed observations such as measurements of core versus surface temperatures were not conducted at the time of care. There was little variation in coverings or room temperatures during times of isolated sleeping and bed sharing in these cases because they occurred in a hospital setting. An instance of a temperature rise associated with use of a wool sweater in Patient 2 was noted in the case description. The temporal association between onset of the adverse events and bed sharing, the lack of recurrence when bed sharing was discontinued or modified, and the elimination of other etiologic causes in both cases appear to be indicators of an association between the health problems and bed sharing. It is recognized that this does not amount to an absolute correlation. However, both the occurrence of "overlay" injury and hyperthermia during bed sharing with younger, "normalized" children have been previously noted in the medical literature, as described above.

Regarding "overlay" injury, lack of motor ability to escape coupled with lack of sensation to recognize the need to escape or to cry out in discomfort may predispose CSHCN to injury to the involved areas, such as in Patient 1. Paralytic osteoporosis may further exacerbate the susceptibility to overlay pressure injury. Unexpected lower extremity fractures of unknown origin in children with spina bifida and SCI are a well-known phenomenon. Inquiries about sleeping habits might be added to investigations of the etiology of these fractures.

Poikilothermia, marked by significant impairment of mechanisms for heat dissipation, may occur in a variety of disorders. (58) Individuals with SCI at thoracic and lower levels have been shown to be able to maintain a normal core body temperature in ambient temperature ranging from 18 [degrees]C to 40 [degrees]C. (59,60) However, patients with SCI above T8 level may become poikilothermic in response to environmental cooling or heating due to the disruption of the autonomic system for thermal regulation. Significant brain injury to the hypothalamic area may further alter ability to respond to environmental temperatures. In addition, children's lesser physical ability to retain heat from external sources makes them susceptible to hyperthermia. The child described in Patient 2, who had a hypothalamic injury, developed elevated temperatures, likely due to overdressing in one instance and close body contact during bed sharing in two other instances, which may have led to unnecessary laboratory investigations for possible infection-induced fever and therefore unnecessary pain for the child and additional costs for his care.

The child described in Patient 1 had a T2 spinal cord injury that would make her prone to poikilothermia. Thus, this child could be at greater risk for overheating caused by body heat from a close sleeping companion, although the evidence for hyperthermia as a result of sustained close contact in addition to temperature elevation due to the fractured femur was limited. However, when bed sharing was discontinued, the fever swiftly resolved and did not recur. This child also underwent multiple diagnostic tests with both additional cost and discomfort to the patient.

Although neither case was observed under strictly controlled conditions, the fact that they occurred in a hospital setting allowed for first-person reporting of the events by medical personnel. Because reports of the possible adverse effects of bed sharing among CSHCN are lacking, the author believes that it is important to report these cases to raise awareness about the possibility that bed sharing may carry particular risks for CSHCN and to stimulate more detailed assessments of future similar occurrences. It is a matter of speculation whether the dearth of reports about injuries possibly or likely sustained as a result of bed sharing reflects a true low incidence of such events or rather a lack of recognition or other reason that leads to failure to report such cases. However, the two cases described in this paper suggest the need for greater and closer observation for such events to avoid physical injury and the pain and expense of unnecessary diagnostic evaluations or treatments.

Conclusion

The two case reports summarized here are limited by the fact that the etiologies of bed sharing leading to fracture secondary to overlay or to hyperthermia secondary to close adult body contact with a child with poor thermal regulation can be made only by exclusion of other etiologies and by temporal association. In Patient 1, no other cause could be found that could be associated with the acute swelling and presence of fracture that occurred during the appropriate time frame. Hyperthermia appeared to be temporally associated with the incidence of bed sharing in these two cases. Thus, there do seem to be risk factors that may precipitate adverse effects from bed sharing in some CSHCN.

Healthcare providers for CSHCN should monitor and report both nonfatal and fatal incidents. Healthcare providers for CSHCN should also consider inquiry about sleeping arrangements when unexplained fractures occur in patients with SCI or spina bifida. When bed sharing is acknowledged, physicians and guardians should mutually review issues of safety as well as benefits related to this practice based on the child's particular impairments. Although this report involves impairments of thermal regulation from brain injury or absent sensation awareness and osteoporosis from SCI, one may need to consider the potential risk factors from other similar disorders (ie, osteogenesis imperfecta, spina bifida, etc.) While physicians are encouraged to respect the family's choices, (61) physicians also have a responsibility to promote their patients' safety and to be aware of conditions that could pose risks. In addition, adverse events associated with bed sharing should be further investigated and reported whenever possible to determine if bed sharing does indeed carry special risks for CSHCN. At the same time, researchers also should investigate the overall incidence of bed sharing in CSHCN and whether bed sharing may have certain beneficial effects for different categories of CSHCN.

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If one is lucky, a solitary fantasy can totally transform a million
realities
--Maya Angelou

Raphael C. Sneed, MD

From the Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS. There were no financial arrangements, products or conflicts of interest involved with the production of this report. No funds were used for this report.

Reprint requests to Raphael C. Sneed, MD, Children's Rehabilitation Services, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505. Email: [e-mail]

Accepted February 28, 2006.

RELATED ARTICLE: Key Points

* The issue of bed sharing involving adults and children has been an ongoing matter of debate in the medical literature in regards to both cultural practices and the potential risks and benefits associated with the practice.

* In instances where a child has special healthcare needs, bed sharing may present a different set of benefits and risks than in "normalized" children.

* Bed sharing with children with special healthcare needs (CSHCN) may result in adverse effects, such as a fracture in a child with paralysis and lack of sensation, or elevated body temperatures in a child with poikilothermia.

* While physicians are encouraged to respect the family's choices, healthcare providers also have a responsibility to promote their patients' safety and to be aware of conditions that might pose risks.