Author’s Response

Mr Cooper and Dr Frankel have questioned the recommendation that infants sleep in the parental bedroom, on a separate sleep surface close to the parents’ bed, ideally for 1 year but at least for 6 months.¹

First, we would like to note that the 2016 policy statement is not significantly different from the 2011 policy statement with regard to room-sharing. For some inexplicable reason, the media chose to highlight the “room-sharing ideally for a year, but at least for 6 months” as an important and more stringent change. In fact, in 2011, our recommendation was that all of the recommendations should be followed until the infant is 1 year of age. Thus, this advice was a loosening of the recommendations. We believe that the most important changes in the recommendations about sleep location are as follows: (1) infants should never fall asleep on couches, sofas, or cushioned chairs; and (2) parents who might fall asleep while feeding their infant in their adult bed should rid the bed of any extraneous bedding.

Case-control studies in England, New Zealand, and Scotland have shown that room-sharing decreases the risk of sudden infant death syndrome compared with sleeping in a separate room. Our statement that the decline in risk was ∼50% is very conservative. The study by Blair et al² found that the adjusted odds ratio of death for infants who slept in a separate room, compared with those who slept in the parents’ room, was 10.49 (95% confidence interval [CI], 4.26–25.81). The New Zealand Cot Death study found that infants who room-shared for the last sleep had a 65% lower risk of death, compared with sleeping in a separate room (adjusted odds ratio, 0.35 [95% CI, 0.26–0.49]), and usual room-sharing had a similar protective effect.³ Tappin et al⁴ reported that the adjusted odds ratio of death when sleeping in a separate room, compared with room-sharing, was 3.26 (95% CI, 1.03–10.35). Although the study by Tappin et al only found this reduction in risk to be present if the parent was a smoker, Blair reported this reduction to be present for both smoker and nonsmoker parents (P. Blair, personal communication, 2016). Furthermore, the most recent data from the New Zealand sudden and unexplained death in infancy study found a 64% protection with room-sharing, compared with solitary sleeping (adjusted odds ratio, 0.36 [95% CI, 0.19–0.71]) (E. Mitchell, personal communication, 2016). Unfortunately, these studies did not stratify the risk according to infant age in months, which is why we recommended in 2011 that the guidelines be followed for the first year. However, more recent analyses of case-control studies^5,6 and registry databases⁷ emphasize the importance in general of sleep location in the first few months of the infant's life, which seems to be a very vulnerable time. Ninety percent of sleep-related deaths occur in the first 6 months, and the peak occurs between 1 and 4 months of age.

An infant’s ability to arouse is critical physiologically, and a leading hypothesis is that failure to arouse makes infants vulnerable to sudden infant death syndrome.⁸ The failure to arouse may explain why prone sleeping is so dangerous; infants who sleep prone have higher arousal thresholds. Room-sharing infants have more small awakenings (which may manifest as stirring or moving around and not full awakening) during the night.^9,10 It has been postulated that room-sharing without bed-sharing may offer a protective effect from the small awakenings. Furthermore, room-sharing facilitates continued breastfeeding,¹¹ another measure that reduces the risk.

One study that has looked at the impact of room-sharing on parental sleep quality found that room-sharing mothers have more sleep disturbances than mothers who sleep in a separate room.¹² In this study, room-sharing and solitary sleeping infants have similar sleep quality. Other studies have found that room-sharing infants experience more frequent awakenings.^9,10 On the other hand, some studies have shown that the sleep quality of breastfeeding mothers (who are more likely to be room-sharing) is similar to or better than that of formula-feeding mothers and that sleep quantity in these 2 groups is similar.^13,14 One study found that mothers who exclusively breastfeed sleep, on average, 30 minutes longer than formula-feeding mothers.¹⁴

Clearly, more research is needed to better understand the physiology of infant sleep and arousal when infants room-share with their parents, as well as the downstream consequences of room-sharing on parental and child sleep.

• Copyright © 2017 by the American Academy of Pediatrics