Should You Co-Sleep With Your Baby?

Every sleep-deprived parent has a story about getting their baby to sleep. Our infant daughter required 30 minutes of one of us bouncing on an exercise ball while she was strapped to one of our chests; in lieu of a lullaby, They Might Be Giants’ “Mickey Mouse Clubhouse Theme” — at full blast — seemed to lull her to sleep.

But what may be the most common method around the globe — sleeping in the same bed as the baby — is often not mentioned. Although the number of parents who sleep in the same bed as their baby is likely in the millions, according to James McKenna, PhD, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame, the practice has been discouraged by the American Academy of Pediatrics (AAP), citing it as a risk factor in the 3,500 sleep-related deaths of infants every year.

The AAP has acknowledged that the practice is prevalent and did update its guidelines a few years ago; however, they included a recommendation that parents sleep in the same room — but not the same bed — as their baby.

McKenna, who holds a doctorate in biological anthropology and has been studying mother-and-infant sleep since his son was born in 1978, goes a step further, offering detailed safety guidelines for parents who bed-share. It’s essential information, says McKenna, the author of Sleeping With Your Baby: A Parent’s Guide to Cosleeping, for bed-sharing parents who may feel shamed into not talking about it. Doctors and clinics complying with the AAP approach, McKenna says, often don’t want to offer advice about it, even though many, like McKenna, may disagree with the oversimplicity of the AAP guidelines.

“Mothers are lying to physicians because there is no ability to have an honest, bidirectional conversation,” McKenna says. “So many moms take their babies to bed and feel terrible even though breastfeeding and bed-sharing are functionally integrated and evolved as one biological system.

The AAP declined an interview request, but here McKenna shares pointers on various sleeping environments, since, as he puts it, he’s “never known any baby who encountered only one sleeping environment.”

Experience Life | Can you explain your definition of co-sleeping?

James McKenna | It’s really a fairly simple concept. The form it takes varies as much as the different cultures doing it. All it refers to is sleeping within sensory proximity and/or contact with each other to be able to detect and respond to the cues of the other.

EL | What does that look like across different cultures?

JM | It could be baskets hanging from the ceiling, hammocks, or a bassinet right next to the bed within arm’s reach. There are futons used in Japan and cradle boards used by the Navajo. It  usually reflects the kind of resources available to create sleeping structures.

EL | Can you explain the term “separate-surface co-sleeping”?

JM | It just means that mother and baby are on different surfaces, so that would not include bed-sharing.

EL | And also your term “breastsleeping”?

JM | When babies are in need, even if both mom and baby are exhausted, they are biologically designed to reach for each other. Many mothers never intended to bed-share, but it emerges because it makes breastfeeding — managing her milk supply —  and sleep easier. That’s why I coined the term “breastsleeping,” when co-sleeping and breastfeeding occur in the absence of all other independent hazards.. . . It’s the most optimal way to co-sleep because breastfeeding affects the physiological statuses of both the mother and infant in clinically positive ways, making the bed-sharing aspect safer.

EL | How so? 

JM | The first thing it does is induce more arousals [wake-ups] in each other — as well as more breastfeeds, providing practice at arousing, which is an important acquired skill permitting babies to reinitiate breathing following an apnea during sleep, for example. After about a month, babies gradually have to use cortical (higher-brain) structures to purposefully reinitiate a breath after an apnea because they lose the gasping reflex during this early period after about a month. Up until about a month it is a reflex that’s unconscious and lower-brainstem-based. While breastsleeping, both sleep lighter, too, because of the exchange of sensory-based signals mutually regulating each other. And more sleep is spent in lighter stages [stages 1 and 2, which] are safer for baby; deeper sleep means it’s harder for them to wake up, including when they are in danger. It is biologically normative for baby to spend most sleep time in stages 1 and 2, rather than 3 or 4 , as the baby responds to mother’s vocalizations, signals, smells, and movements. Moms spend time in lighter stages of sleep, too — and thus can be more vigilant, making the breastsleeping arrangement even safer. Babies do change everything.

EL | Is there any research that backs that up?

JM | In one study that looked at 37 moms and babies in our sleep laboratory, we found two things: Mothers and babies who bed-shared got more sleep in minutes, and 70 percent of the moms said it was “enough” or “good,” compared with 54 percent of the moms who slept in a different room than their baby. (We had everyone sleep as they do at home for the first night, switched for the second night, and then did the opposite the third night.) Moms and babies who co-slept moved their breathing patterns to sync with each other. When the babies slept separately, sleep patterns were very, very different.

EL | Can you bottle-feed and co-sleep?

JM | I do believe that a bottle-feeding mother can remain vigilant enough to protect her baby if bed-sharing, but she will need to make sure she really psychologically commits to being aware of the baby’s presence while asleep. I am most comfortable with being able to recommend bed-sharing (in the absence of hazardous factors) if breastfeeding is involved, because of the ways the breastfeeding itself changes not only the baby’s sleep behavior and physiology, but the mother’s, too. When breastfeeding, there are lots of arousals [wake-ups], lots of brief awakenings to oxygenate, and the baby remains for longer periods in lighter sleep. A bottle-feeding mother spends more time in deep sleep (as does her baby), with fewer arousals for both mother and infant, which means she might not be as able to monitor her infant and respond to the baby’s signals, cues, and overall needs. Moreover, bottle-fed babies move around in the bed more, while breastsleeping babies stay put at chest level in the direction of their mothers and do not risk falling off the bed or into a gap or hole created by a space between a headboard and mattress.

[That said,] what I really think should be avoided is making declarative statements about what never to do, except where it is something specific like “do not put your infant prone,” “do not sleep with your baby if drunk or desensitized by drugs,” “do not sleep with your baby on couches, sofas, chairs, or recliners.” [I’d guess] hundreds of thousands of nonbreastfeeding mothers (and fathers) are sleeping with their babies, and it does not mean it is necessarily too risky at all. . . . Every family should be informed about what they can do to maximize safety, even telling parents, “If you sleep with your baby, make sure the adult in the bed is aware the baby is there. Make sure each adult internalizes that he or she must be aware of the baby even in their sleep, like saying to yourself, “Baby in bed!” This actually works.

EL | Can you bed-share safely? How?

JM | In urban, industrialized environments where we have beds and bedframes, etc., you have to be conscious of what is not beneficial: blankets, bedding, spaces between the mattress and the headboard, for example. Never bed-share if you smoked during your pregnancy — that potentially damages an infant’s arousal mechanisms — and never bed-share while under the influence of drugs or alcohol. Being prepared is important because more education, not less, can make it safer. And that’s being denied to parents. [It’s] a situation where informed professionals are being threatened with their jobs should they teach safer bed-sharing in or around the hospital. It’s totally unethical to hold back the information that we have. Lactation counselors would never recommend that any particular family should bed-share, as they have no idea what the circumstances are; but to ban them from saying anything that could reduce sleep-related deaths is unethical and puts health providers at odds with their own ethical judgments.

EL | Why is it being denied?

JM | The AAP thinks that by raising co-sleeping/bed-sharing safety factors they are endorsing the practice, or that parents will think they think it’s OK, but the risks of not telling or holding back easy, simple safety information, like keeping other children away from the bed-sharing baby, is very important and can make a huge difference. It is absolutely unconscionable what is going on in hospitals when lactation counselors and specialists are being told that if they even mention co-sleeping they will be fired, and that life-saving information is being withheld. Parents are being left with the impression that they have no rights to decide how to care for their babies in this way, and this is a violation of the parents’ and the babies’ civil liberties, when the bed-sharing is being done responsibly.

EL | What about the AAP citing co-sleeping as a risk factor in the 3,500 sleep-related deaths of infants annually?

My response to this statistic is that in every way possible this number skips over and dismisses the details of each death, wherein the vast majority of these tragic deaths are associated with multiple independent risks separate from the act of bed-sharing itself; rather, they need reference to the circumstances and the conditions within which the bed-sharing took place. When those details are examined it becomes not quite so simple or necessarily even accurate to use this number as a justification for recommending against any and all bed-sharing, as many prominent SIDS researchers and prestigious organizations like the World Health Organization, UNICEF, and lactation support and counseling organizations around the world maintain.

EL | What are the biggest risk factors associated with Sudden Infant Death Syndrome (SIDS)?

JM | Prematurity; a gestation in which the fetus experiences its mother smoking; formula or bottle feeding; putting baby to sleep prone (on stomach); sleeping on soft surfaces, sofas, couches, recliners (although the risk with soft surfaces may be suffocation rather than SIDS).

EL | How long do you recommend some form of co-sleeping?

JM | The optimal recommendation is the first six to 12 months. Babies’ brains are only at 25 percent of their adult volume in the first year. When the baby is sleeping, it’s like the baby’s brain is going to school. By giving that baby a cumulative sensory stimulation, you’re creating the architecture of baby’s brain: optimizing potential for talents, resilience, intellectual achievements. The early experiences of baby’s day-to-day really matter. But we Westerners tend to think there are these artificial cutoffs. There’s really no “When should you stop this?” There’s nothing wrong with it as long as it’s a good relationship. [But] if it starts bothering the parent, then don’t do it — it’s not healthy when anyone is unhappy with something relational like this.