Parenting in the Dark:  What’s a Mother to Do?

By Barbara Behrmann, Ph.D.

(c) 2005

For decades, parents have been bombarded with information about how to keep babies healthy and safe.  Sometimes advice is based on sound science.  But other times it is based on ideology masking as science.  Even more problematic is when one piece of information seems to contradict another, particularly when coming from the same source. 

The latest example comes from the American Academy of Pediatrics.  In February 2005 the AAP revised their statement on breastfeeding, expressing stronger support than ever before.  Acknowledging the risks of formula to the tune that 3.6 billion dollars is spent annually in the U.S. to care for non breast-fed babies, the statement calls on pediatricians and other health care providers to promote breastfeeding as a cultural norm and asserts that one of the best ways to facilitate breastfeeding is for mother and infant to “sleep in proximity to each other.”  

But “in proximity” apparently doesn’t mean “with.”  And this is where things get muddied.  In October, as part of their effort to reduce SIDS (Sudden Infant Death Syndrome), the same organization revised its policy statement on SIDS and infant sleep.  Clearly stated in the document is that parents should never sleep with their babies: “Infants may be brought into bed for nursing or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep.  The infant should not be brought into bed when the parent is excessively tired…”

In reality, that means everyone.  Because what new mother is not excessively tired?       But do babies really need to be protected against their mother’s potentially dangerous bodies?  And does this latest statement mean that parents should get the baby out of the bed ASAP?  Not necessarily.  

Undermining Breastfeeding

The first problem with this latest recommendation is that it undermines breastfeeding.  Studies reveal what most nursing mothers have figured out:  co-sleeping makes breastfeeding easier.  And when something is easier, people are more likely to do it and keep doing it.   After a few nights of getting in and out of bed, mothers discover they can simply roll over, offer a breast, and get on with their own sleep.  In fact, sometimes they don’t even wake up for the feeding. 

Equally important, studies document that mothers and babies who sleep together nurse more often during the night than those who don’t share sleep.  This helps prevent breast engorgement and breast infections.  And if mothers and babies are separated during the day, nights offer an opportunity a time to catch up on nursing time. 

Intertwined with the relationship between co-sleeping and breastfeeding is that breastfeeding is related to reducing the risk of SIDS.  Babies who sleep alone have more difficulty rousing themselves from deep sleep – a factor that may contribute to SIDS.  Co-sleeping babies, on the other hand, tend to follow the sleep patterns of their mothers, helping them develop more mature sleeping and breathing patterns.

While this doesn’t mean that breastfeeding itself protects against SIDS, the AAP nonetheless recommends breastfeeding for SIDS prevention.  It’s ironic, then, that a parallel situation doesn’t result in a parallel recommendation.  Studies show that it is not bedsharing itself that puts babies at risk, but bedsharing “under certain conditions.” Yet the AAP explicitly asserts that babies should never sleep with their mothers.  And they do so while acknowledging that bed sharing facilitates breastfeeding and mother-baby bonding.

 Confusing the Evidence

The AAP’s recommendation regarding the relationship between bed sharing and SIDS is not based on evidence.  The data simply don’t support the claim that babies are safer when sleeping alone.  When we hear reports of babies dying while sleeping with an adult, in almost all cases, further analysis shows that it is not co-sleeping itself which is the cause, but the circumstances surrounding it; e.g., the parent was intoxicated, the mother smoked during pregnancy (a known risk factor for SIDS), or the sleep surface was too soft, leading to suffocation. For the AAP to make policy recommendations for all mothers and babies based on circumstances in high risk settings or on high risk populations is unscientific and unethical.  

Confusing SIDS with suffocation.

SIDS is defined as unexplained death after a thorough case investigation.  Suffocation is explainable.  It is not SIDS.  When a baby dies because it becomes buried under heavy blankets or smothered by a pillow or too-soft mattress, it is tragic, but not SIDS. 

Parents need is a clear understanding of the risk factors for SIDS and suffocation, for bed sharing and solitary sleeping.   This is not a policy recommendation.  This is education.  It is no different from knowing that children are killed by drunk drivers.  We don’t recommend people abandon their cars; we educate them on how to drive safely.  So it should be with sleep recommendations.

Certain situations do make bed-sharing risky.  Parents who smoke, abuse drugs and/or alcohol, or are heavily medicated should not sleep with their babies.  And babies should never sleep on waterbeds, soft mattresses, with soft bedding materials, or on surfaces that could trap or strangle them, such as a sofa, reclining chair, or mattress that doesn’t tightly intersect the bed frame.  But there are risk factors for babies who sleep by themselves, too.

Confusing Ideology with Science

All sleep environments carry risk.  But ideology and cultural biases affect how we assess it.  “Why do we ask if co-sleeping is safe,” asks James McKenna, director of  the Center for Behavioral Studies of Mother-Infant Sleep at The University of Notre Dame, “when we don’t ask if solitary sleep away from parental contact is safe?”  

When a baby dies in a bed sharing situation, he goes on to assert, the result is in an indictment against bed sharing.  But when a baby dies while in a crib, it merely represents a problem to be solved.  We treat the situations with different degrees of alarm and consequence.

This ideological bias is reflected in the fact that the United States is the only society in which babies most often sleep in their own bed, in their own room.  But 90 percent of babies around the world sleep with an adult, as they have done so for all of human history.  This is the “normal” sleeping arrangement against which other arrangements should be assessed.  We are mammals and mammal babies are designed to sleep with their mothers. 

Unfortunately, co-sleeping in human mammals is not well understood by most American pediatricians, the very people to whom most American parents turn for advice. Meridith Small, author of Our Babies, Ourselves:  How Biology and Culture Shape the Way We Parent, reports that a survey of American pediatricians found that 88 percent advocated for babies to sleep in a crib outside the parents room and 65 percent suggested that babies receive no parental body contact during the night at all![i]  And this was before the AAP’s revised guidelines!

American expectations of babies’ sleep habits are based on formula fed infants who are able to sleep longer and deeper than breastfed babies.  Moreover, because of our culture’s emphasis on privacy and fostering early independence and self-reliance, we have come to view the parental bed as sacred.   But there is a clash between these dominant values and a baby’s biological need for physical contact during the night. 

 Clarity, not confusion

It’s easy to understand how parents would interpret “in proximity” to mean “with.”  Parents need clarity to help them make decisions, not confusion.   But clarity does not mean simplicity.   And telling a sleep-deprived mother to categorically avoid falling asleep with her baby not only creates guilt (and blame, if something goes wrong) but can result in less milk production, less sleep for everyone, and less breastfeeding. 

Instead of asking whether or not bed sharing helps to prevent SIDS, we should be asking, “Is co-sleeping safe?  Is solitary sleeping safe?”  The answer for both is, “It depends.” 

The real issue is how to make it possible for everyone in the family to get a good night’s sleep in a loving and safe way.  Breastfeeding, safe sleep, and compassionate parenting are all important.  Not all women will want to sleep with their babies, nor would this be a responsible recommendation.  But parents should be able to make informed decisions on the basis of facts, not ideology.  

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Barbara L. Behrmann, Ph.D. is a writer, researcher, and author of The Breastfeeding Café: Mothers Share the Joys, Secrets & Challenges of Nursing, University of Michigan Press, 2005. She is a frequent speaker around the country and is available for talks, readings, and conducting birthing and breastfeeding writing circles. The mother of two formerly breastfed children, Barbara lives in upstate New York.