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Helping parents make informed decisions regarding bed-sharing.

Introduction

Bed-sharing is defined as parents and children sleeping in the same bed, or on the same surface (Sobralske & Gruber, 2009). Although bed-sharing is a practice that is deeply rooted in some cultures, there is significant controversy over the advisability of bed-sharing (Homer, Armari, & Fowler, 2012). In 2005, the American Academy of Pediatrics (AAP) released a policy statement that did not recommend bed-sharing (Blabley & Gessner, 2009). This policy statement was in response to a high rate of sudden infant death syndrome (SIDS) and the alleged relationship between SIDS and bed-sharing (Blabley & Gessner, 2009). However, there are many parents who choose to bed-share for reasons of bonding, promoting breastfeeding, parental monitoring of the infant, and decreasing infant arousals (Sobralske & Gruber, 2009). Because parents often seek advice in making decisions regarding whether to bed-share or not, it is crucial that child birth educators become knowledgeable about the pros and cons of this "hot issue."

Historically, bed-sharing was commonplace and well accepted, with both infants and young children. In today's modern societies, the practice is not routine and is something parents and health care personnel consider an option. This change came about as a result of medical recommendations as well as a variety of cultural and personal beliefs (Lujik, et al., 2013). From Dr. Spock's (1976) admonitions that bed-sharing "spoiled" a child to the AAP's warnings that SIDs deaths could be attributed to bed-sharing, acceptability of the practice decreased dramatically. Lately, however, many parents have voiced interest and participation in bed-sharing in light of perceived benefits and little hard evidence to limit it. Western societies, which are typically considered non bed-sharing nations, have shown an increase in bed-sharing in recent years. While an earlier study (Lozoff, Wolf, &

Davis, 1984) reported rates of bed-sharing as high as 70% in African American families, others (Luijk et al., 2013) found that 13% of families in the United States were bed sharing as compared to 6% in 1993. All figures are thought to be low as a result of the generally negative feelings regarding bed sharing.

Child birth educators are seen as valuable resources for all issues related to birthing and raising children. They are instrumental in providing education and recommendations to parents based on knowledge acquired from evidence based practice guidelines. While parents clearly make their own final decisions, they seek advice from trusted sources. Child birth educators need to stay informed and include all the facts about bed sharing to give objective points for the individual family to consider, particularly with this controversial topic.

Background

There are many pros and cons to the practice of bed-sharing. Issues of safety, health, psychological security, cultural values and financial considerations are all factors that enter into a decision to bed share or not. Each factor can have a different impact depending on the age of the child and whether or not the decision to bed share has been a deliberate one (usually based on parental preferences) or happens because the child initiated the practice. There are also different implications based on how often and under what circumstances the bed sharing occurs. Familiarity with all aspects of the topic helps child birth educators discuss bed sharing in an informed manner with interested parents.

Safety

Safety of the child is (and should be) the most important consideration when making any decision about child rearing practices. One of the most significant issues surrounding bed-sharing is whether or not it contributes to higher rates of SIDS, which some professionals propose. Others, including many parents, claim that bed-sharing can actually decrease the incidence of SIDS because the child is closer and any difficulty with breathing or sleep is more noticeable.

The American Academy of Pediatrics has discouraged bed sharing since 1992 due to the belief that bed sharing increases the risk of SIDS (Sobralske & Gruber, 2009). The potential risks include: an infant being overlain by the parent, the infant turning into a prone position, the infant becoming entrapped by soft bedding, the infant getting overheated, and the infant being asphyxiated by the clothing of a parent, particularly one who smokes (Sobralske & Gruber, 2009). In 2005, the American Academy of Pediatrics (AAP) Taskforce revised its 'Safe Bedding Practices for Infants' of 2000. The AAP recommended that 'infants (should) not bed-share during sleep'" (Norton & Grellner, 2011, p. 507). The recommendations from the AAP are from a scientific, medical standpoint aimed to reduce the risk of SIDS.

"The bed-sharing discussion began in earnest when anthropologists proposed that SIDS was a phenomenon of solitary infant sleep and that infants benefitted from the sensory stimulation of sleeping in close proximity to their parents ..." (Ball & Volpe, 2013, p. 85).

Other research suggests that bed-sharing alone does not increase the risk of SIDS and that this recommendation is not valid for all parents or infants. Many parents believe that sleeping with their infant actually reduces the risk of an external threat affecting the child (Chianese, Ploof, Trovato, & Chang, 2009). Parents claim that sleeping with their infant helps them to sense what is happening and more easily monitor the situation (Baddock, Galland, Bolton, Williams, & Taylor, 2006; Chianese et al., 2009; Lozoff, et al., 1984). Parents report feeling they would immediately know if their child was in danger or needed them during the night if they bed-share. Thus, bed-sharing might reduce the risk of SIDS for their child "because the parents would immediately know if the baby stopped breathing" (Chianese et al., 2009, p. 29). Parents choose to sleep with their infants because they feel close to them and want to better protect them.

Health

Good sleep habits and nutrition are both desired for every child by parents and health care workers alike. Getting a good night's sleep has shown to be important for individuals of every age. Breast feeding is the best choice for infants, offering advantages other than simple nutrition. Exploration of how bed-sharing influences these needs is an important consideration when deciding whether or not to bed share.

An infant's inability to self-sooth is highly associated with night wakening and difficulty falling asleep. If an infant can self-sooth, then he is more likely to have better sleep and to sleep throughout the night. Self-soothing is a learned trait. The issue becomes, do infants learn this better alone or with their parents? One study concluded "Overall, children who sleep in a separate room obtain more sleep, wake less at night, have less difficulty at bedtime, fall asleep faster, and are perceived as having fewer sleep problems" (Mindell, Sadeh, Kohyama, & How, 2010, p. 396), but this has not been universally supported.

Parents choose to co-sleep reporting they feel closer to the child.

Evidence indicates that sleep problems are a reason for initiating bed sharing in school age children (Jain, Romack, & Jain, 2011). One problem is sleep onset associations. This is defined as the need to reproduce the exact conditions/routine that occur at bedtime, when the child first falls asleep. This means that if the child first falls asleep with the parents present, when she awakes during the night hours without the parents she will not be able to return to sleep without the parents present (Jain et al., 2011). This can initiate the beginning of bed-sharing.

Breastfeeding is a healthier source of nutrition for the infant and beneficial to the mother. Breastfeeding reduces the risk of SIDS. Women who breastfeed are more likely to bed-share with their infant, and they tend to breastfeed for a longer period of time (Ball & Volpe, 2013). Parents report that it is much more convenient if the infant sleeps with them to breastfeed. The parents or baby do not have to fully wake in order to respond to feeding cues (Baddock et al., 2006; Chianese et al., 2009).

Psychological Security

Some parents bed-share for emotional reasons. Parents describe feeling pleasure, closeness, and comfort when bed sharing with their infant (Baddock et al., 2006; Chianese, et al., 2009). Maternal bonding and maternal sleep are also associated with bed-sharing in a positive manner (Krouse, Craig, Watson, Matthews, Kolski, & Isola, 2012). Skin-toskin contact between the infant and mother can moderate crying and cortisol stress levels in infants (Homer et al., 2012). Bed-sharing allows parents to bond with their child during sleep when they are not able to spend much time with them while awake. This can be true for parents who have to spend a lot of time away from their child due to work, divorce, or other factors. Parents of more than one child may report not having adequate bonding time with each individual child during waking hours.

Short-term observational studies have shown that infants "experience more touching and looking, increased breastfeeding, with faster and frequent maternal response" (Jain et al., 2011, p. 187). Jain et al. (2011) reviewed several studies looking at a variety of psychological factors. Overall very little was concluded from their literature survey. "The results indicated neither positive nor negative consequences for bed-sharing children at any age." (Jain et al., 2011, p. 187). Studies explored behavioral problems, overall mood, persistence, cognitive abilities, social, emotional and developmental maturity, sleep problems and creativity. Although individual studies resulted in different findings, no consistent pattern emerged that supported or did not support bed-sharing. Parents, and children alike, may feel the sleeping environment is a safe and comfortable place. As the family practices sleeping in the same bed the child may feel like she is receiving more attention from the parent and this could make her feel more at ease and secure. On the other hand, it could be argued that bed-sharing might cause the child to be more insecure because he cannot sleep alone. Again, the evidence, to date, indicates no specific positive or negative effects on child development.

The emotional life of parents is significantly altered by the birth of a child. A myriad of feelings are part of the new experience; there is generally overwhelming joy as well as some degree of negative thoughts due to the inevitable disruption in the household. The issue of bed-sharing is one that a couple must discuss and come to agreement on so as not to create additional stress and strain due to the arrival of a new member of the family. Both fathers and mothers need to consider the advantages and disadvantages to bed-sharing in the context of their marriage relationship.

Messmer, Miller, and Yu (2012), examined the degree of marital satisfaction for mothers that are intentional (parent initiated) versus reactive (child initiated) bed-sharers. The results of the study indicate that "the relationship between time spent bed-sharing and marital satisfaction would be moderated by classification as an intentional or reactive bed sharer" (Messmer et al., 2012, p. 806). In other words, reactive bed-sharers have a significant decrease in their marital satisfaction, while intentional bed-sharers did not experience this decrease in marital satisfaction.

Cultural Values

Sleeping patterns are strongly influenced by culture. A study that examined the sleeping patterns of Japanese and American families found that Japanese families shared their beds at least three nights a week, while the American families participated in bed-sharing less than three nights per week (Sobralske & Gruber, 2009). Bed-sharing "is common and seen as a healthy bonding experience in many cultures worldwide; warmth, protection, and a sense of well-being are factors suspected as being incentives to co-sleep" (Sobralske & Gruber, 2009, p. 474). "Beyond Western post-industrial settings with medicalized infant-care, mother-infant sleep contact remains the cultural norm, and babies sleep in contact with a care-giver night and day" (Ball & Volpe, 2013, p. 86). "For many groups of parents, bed-sharing forms part of their cultural or personal identities, so the message to desist is unacceptable and rejected" (Ball & Volpe, 2013, p. 89). These cultural values should be respected, even if out of the norm in one's own beliefs.

Overall bed-sharing is less prevalent in cultures that consider autonomy and individualism to be valuable attributes. Parents in western cultures want to instill independence early on in the life of their child thus resulting in solitary infant sleep patterns (Luijk et al., 2013). The United States is a multi-cultural country with many different viewpoints regarding bed-sharing. Jain, et al.(2011) report significant differences in the incidence of bed-sharing among African Americans (27.9%), Asians (20.9%), and Caucasian families (7.2%). As stated earlier, there has been an increase overall in the rate of bed sharing in the United States in recent years. This could be due to the diverse cultures that make up the United States or it could be that Americans in general are beginning to favor bed-sharing.

Financial Considerations

"Among the widely reported factors associated with a greater prevalence of bed-sharing are socioeconomic factors like lower family income ..." (Luijk et al., 2013, p.1093). Parents without the financial ability to have access to safe cribs tend to sleep with their infants. Other financial factors that can influence bed-sharing in all ages include the lack of sleeping areas and the lack of heat in the home. With a limited number of bedrooms, the entire family may practice sleeping together in one area or on the same surface. If there is no heat, they are also more likely to bed-share for maximizing warmth.

Role of the Child Birth Educator

Child birth educators may be consulted on the topic of bed-sharing. Even if the parents do not ask, it can be helpful to open the subject for discussion and provide information to help have a plan in mind. If parents are electing to bed-share then providing them with research results promotes the safest method to engage in the practice.

Children's Medical Center in Dallas, Texas developed safety guidelines to give to parents if they are going to co-sleep with an infant. According to the safety guidelines the sleeping should take place on a firm mattress, beds should not have railings or headboards, beds should not be placed directly against a wall, heavy blankets should not be used during sleep, and never sleep on a sofa with an infant (Sobralske & Gruber, 2009). These guidelines should be shared with parents to help them create a safe environment for the infant. Armed with information, parents can more easily make the informed decision which will work best for their family.

Thorough sleep assessments should be done and should include the family's routine, cultural beliefs, sleep hygiene practices, economic status, environmental factors, and parental work patterns (Sobralske & Gruber, 2009). If bed-sharing is in practice, it should be determined whether the parents are doing so intentionally or reactively and whether it is because of perceived sleeping problems or real sleeping problems (Sobralske & Gruber, 2009). If the parents report the infant does not have a regular sleeping pattern or sleep hygiene is not in place, this is an indicator that education regarding sleep hygiene should occur. Lastly a physical examination can assess for any illness that might affect the infant's sleep, such as respiratory, cardiac, or neurological problems (Sobralske & Gruber, 2009).

Healthy sleep hygiene can be established by implementing the following: sleeping in a dark, quiet, cool area; having a regular sleep schedule, including naps and the infant's bed time; engaging in quiet activities before bedtime; putting infants in bed to sleep when they are drowsy, but not asleep, in order to promote self-soothing; using a transition object for infants 3 months of age and older, such as a blanket, or soft toy; and planning when to move the infant to a crib (Sobralske & Gruber, 2009).

Families should be educated that bed-sharing should never occur when a parent smokes, consumes alcohol, or uses sedating medications (Vennemann et al., 2012). Parents should be reminded that sleeping on an inappropriate sleeping surface, such as a sofa, the risk of Sudden Infant Death Syndrome is highly increased (Vennemann et al., 2012). As with any teaching-learning situation, the child birth educator should make sure that the parent is able to summarize the information back to ensure that the education was understood correctly.

Conclusion

Literature has shown that there are few definitive answers regarding the benefits or risks of bed-sharing. It remains a controversial topic. Research exists indicating it can be both potentially beneficial and harmful to an infant or child. The idea that bed-sharing is harmful comes mainly from a possible increased risk of SIDS in infants that bed-share. However, research indicates that the bed-sharing alone cannot be named the one specific cause of SIDS. "Despite a strong position against parent/child co-sleeping taken by the American Academy of Pediatrics (AAP, 2005), there is little scientific evidence to demonstrate the ill-effects of children sleeping with their parents when done in a safe environment" (Sobralske et al., 2009, p. 474). Likewise bed-sharing is also indicated to be beneficial. Planned bed-sharing can promote breastfeeding, encourage a non-prone sleeping position for infants, increase maternal bonding, and provide more infant arousal (Sobralske et al., 2009).

Bed-sharing is also becoming a more common practice among families in the United States. "In one U.S. study, over 35% (n = 615) of families reported frequent co-sleeping and 76% (n = 1, 335) at least sometimes" (Sobralske et al., 2009, p. 475). Some research reports that the actual practice of bed-sharing is more prevalent in the United States than is reported. This is based on the assumption that U.S. families do not always report they actually do bed-share because of the societal pressure against bed-sharing (Sobralske et al., 2009).

Further research is indicated to provide a clearer understanding of the risks and benefits associated with bed-sharing. The available literature essentially leaves the decision of whether bed-sharing is a good or bad practice up to the reader. Although the AAP does provide a recommendation against bed-sharing there has been an increase in the number of bed-sharing families in the United States. This seems to indicate that even though the recommendation exists families are beneficially reinforced in other ways.

Childbirth educators can help the family to consider the infant's safety above everything else when discussing sleep arrangements. Presenting information will promote a better understanding of bed-sharing. Until more is known on this "hot issue, " guiding families to their own conclusions regarding the desirability of bed-sharing for their family, based on existing evidence, is a service that can easily be provided.

References

Baddock, S., Galland, B., Bolton, D., Williams, S., & Taylor, B. (2006). Differences in infant and parent behaviors during routine bed sharing compared with cot sleeping in the home setting. Pediatrics, 1/7(5), 1599-1607.

Ball, H. L. & Volpe, L. E. (2013). Sudden infant death syndrome (SIDS) risk reduction and infant sleep location--moving the discussion forward. Social Science & Medicine, 79(February 2013), 7984-91.

Blabley, M. & Gessner, B. (2009). Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska. Public Health Reports (Washington, D.C.: 1974), 124(4), 527-534.

Chianese, J., Ploof, D., Trovato, C., & Chang, J. (2009). Inner-city caregivers' perspectives on bed sharing with their infants. Academic Pediatrics, 9(1), 26-32.

Homer, C., Armari, E., & Fowler, C. (2012). Bed-sharing with infants in a time of SIDS awareness. Neonatal, Paediatric & Child Health Nursing, 15(2), 3-7.

Jain, S., Romack, R., & Jain, R. (2011). Bed sharing in school-age children clinical and social implications. Journal of Child & Adolescent Psychiatric Nursing, 24(3), 185-189.

Krouse, A., Craig, J., Watson, U., Matthews, Z., Kolski, G., & Isola, K. (2012). Bed-sharing influences, attitudes, and practices: implications for promoting safe infant sleep. Journal of Child Health Care, 16(3), 274-283.

Lozoff, B., Wolf, A., & Davis, N. (1984). Cosleeping in urban families with young children in the United States. Pediatrics, 74(2), 171-182.

Luijk, M., Mileva-Seitz, V., Jansen, P., van Ijzendoorn, M., Jaddoe, V., Raat, H., Hofman, A., Verhulst, F, & Tiemeier, H. (2013). Ethnic differences in prevalence and determinants of mother-child bed-sharing in early childhood. Sleep Medicine, 14(11), 1092-1099.

Messmer, R., Miller, L. D., & Yu, C. M. (2012). The relationship between parent-infant bed sharing and marital satisfaction for mothers of infants. Family Relations: An Interdisciplinary Journal of Applied Family Studies, 61(5), 798-810.

Mindell, J. A., Sadeh, A., Kohyama, J., & How, T. (2010). Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Medicine, 11(4), 393-399.

Sobralske, M. & Gruber, M. (2009). Risks and benefits of parent/child bed sharing. Journal of the American Academy of Nurse Practitioners, 2/(9), 474-479.

Spock, B. (1976). Baby and Child Care. Pocket Books: New York.

Vennemann, M., Hense, H., Bajanowski, T., Blair, P., Complojer, C., Moon, R., & Kiechl-Kohlendorfer, U. (2012). Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate? The Journal of Pediatrics, 160(1), 44-48.

by Natosha L. Matlock-Carr, MSN FNP-C and Karen S. Ward, PhD RN COI

Natosha Matlock-Carr lives in Northeast Tennessee with her husband of six years and their daughter. She holds a BSN from East Tennessee State University and a MSN from Middle Tennessee State University. She is a Family Nurse Practitioner practicing in Kingsport, TN. Bed-sharing is important and interesting to her because she has a toddler and is a health care provider.

Karen S. Ward holds a BSN and MSN from Vanderbilt University (Nashville, TN) and a PhD in developmental psychology from Cornell University (Ithaca, New York). She is a Professor of Nursing at Middle Tennessee State University. Her interest in bed-sharing peaked when her children started intentionally bed-sharing with her grandchildren.
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Author:Matlock-Carr, Natosha L.; Ward, Karen S.
Publication:International Journal of Childbirth Education
Article Type:Report
Date:Jan 1, 2015
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