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Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
Letter to the Editor

Author’s Response

Rachel Y. Moon, AAP Task Force on SIDS, Rachel Y. Moon, Robert A. Darnall, Lori Feldman-Winter, Michael A. Goodstein, Fern R. Hauck, Consultants:, Carrie A. Shapiro-Mendoza, Marian Willinger, Staff: and James Couto
Pediatrics March 2017, 139 (3) e20164132C; DOI: https://doi.org/10.1542/peds.2016-4132C
Rachel Y. Moon
Professor of Pediatrics, University of Virginia
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Professor of Pediatrics, University of Virginia
Rachel Y. Moon
Professor of Pediatrics, University of Virginia
Roles: Chair
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Robert A. Darnall
Professor of Pediatrics, University of Virginia
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Lori Feldman-Winter
Professor of Pediatrics, University of Virginia
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Michael A. Goodstein
Professor of Pediatrics, University of Virginia
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Fern R. Hauck
Professor of Pediatrics, University of Virginia
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Professor of Pediatrics, University of Virginia
Carrie A. Shapiro-Mendoza
Professor of Pediatrics, University of Virginia
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Marian Willinger
Professor of Pediatrics, University of Virginia
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Professor of Pediatrics, University of Virginia
James Couto
Professor of Pediatrics, University of Virginia
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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 studies5,6 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.

Footnotes

  • E-mail:
    rym4z{at}virginia.edu
  • CONFLICT OF INTEREST: None declared.

References

  1. ↵
    Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Blair PS,
    2. Fleming PJ,
    3. Smith IJ, et al
    . Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI Research Group. BMJ. 1999;319(7223):1457–1461
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Mitchell EA,
    2. Thompson JMD
    . Co-sleeping increases the risk of SIDS, but sleeping in the parents’ bedroom lowers it. In: Rognum TO, ed. Sudden Infant Death Syndrome: New Trends in the Nineties. Oslo, Norway: Scandinavian University Press; 1995:266–269
  4. ↵
    1. Tappin D,
    2. Ecob R,
    3. Brooke H
    . Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study. J Pediatr. 2005;147(1):32–37
    OpenUrlCrossRefPubMed
  5. ↵
    1. Carpenter R,
    2. McGarvey C,
    3. 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(5):e002299
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Blair PS,
    2. Sidebotham P,
    3. Pease A,
    4. Fleming PJ
    . Bed-sharing in the absence of hazardous circumstances: is there a risk of sudden infant death syndrome? An analysis from two case-control studies conducted in the UK. PLoS One. 2014;9(9):e107799
    OpenUrlCrossRefPubMed
  7. ↵
    1. Colvin JD,
    2. Collie-Akers V,
    3. Schunn C,
    4. Moon RY
    . Sleep environment risks for younger and older infants. Pediatrics. 2014;134(2). Available at: www.pediatrics.org/cgi/content/full/134/2/:e406
  8. ↵
    1. Harper RM,
    2. Kinney HC
    . Potential mechanisms of failure in the sudden infant death syndrome. Curr Pediatr Rev. 2010;6(1):39–47
    OpenUrlCrossRefPubMed
  9. ↵
    1. Mao A,
    2. Burnham MM,
    3. Goodlin-Jones BL,
    4. Gaylor EE,
    5. Anders TF
    . A comparison of the sleep-wake patterns of cosleeping and solitary-sleeping infants. Child Psychiatry Hum Dev. 2004;35(2):95–105
    OpenUrlCrossRefPubMed
  10. ↵
    1. Mindell JA,
    2. Sadeh A,
    3. Kohyama J,
    4. How TH
    . Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Med. 2010;11(4):393–399
    OpenUrlCrossRefPubMed
  11. ↵
    1. Smith LA,
    2. Geller NL,
    3. Kellams AL, et al
    . Infant sleep location and breastfeeding practices in the United States, 2011-2014. Acad Pediatr. 2016;16(6):540–549
    OpenUrlCrossRefPubMed
  12. ↵
    1. Volkovich E,
    2. Ben-Zion H,
    3. Karny D,
    4. Meiri G,
    5. Tikotzky L
    . Sleep patterns of co-sleeping and solitary sleeping infants and mothers: a longitudinal study. Sleep Med. 2015;16(11):1305–1312
    OpenUrl
  13. ↵
    1. Montgomery-Downs HE,
    2. Clawges HM,
    3. Santy EE
    . Infant feeding methods and maternal sleep and daytime functioning. Pediatrics. 2010;126(6). Available at: www.pediatrics.org/cgi/content/full/126/6/e1562
  14. ↵
    1. Doan T,
    2. Gay CL,
    3. Kennedy HP,
    4. Newman J,
    5. Lee KA
    . Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum. J Clin Sleep Med. 2014;10(3):313–319
    OpenUrl
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Author’s Response
Rachel Y. Moon, AAP Task Force on SIDS, Rachel Y. Moon, Robert A. Darnall, Lori Feldman-Winter, Michael A. Goodstein, Fern R. Hauck, Consultants:, Carrie A. Shapiro-Mendoza, Marian Willinger, Staff:, James Couto
Pediatrics Mar 2017, 139 (3) e20164132C; DOI: 10.1542/peds.2016-4132C

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Author’s Response
Rachel Y. Moon, AAP Task Force on SIDS, Rachel Y. Moon, Robert A. Darnall, Lori Feldman-Winter, Michael A. Goodstein, Fern R. Hauck, Consultants:, Carrie A. Shapiro-Mendoza, Marian Willinger, Staff:, James Couto
Pediatrics Mar 2017, 139 (3) e20164132C; DOI: 10.1542/peds.2016-4132C
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