The American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months ( Pediatrics. 2016 Oct;138[5]:e20162938 ). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.
Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” ( Lancet. 1996 Jan 6;347[8993]:7-12 ).
In another frequently referenced paper from England, Blair et al. suggest that “further research is required to investigate whether room sharing is protective in itself or merely a matter of hidden confounders not measured in this study” ( BMJ. 1999 Dec 4; 319[7223]:1457-62 ). While it may be that room sharing has some positive effect, do we have any sense of its magnitude? And, is that effect large enough to make the recommendation that infants share a bedroom with their parents for the first 6 months?
For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?
Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.
For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.
As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” ( Paediatric Resp Review. 2005, Jun;6[2]:134-52) .
I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.
On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
