Around the 1980s research into Sudden Infant Death Syndrome (SIDS) began, at this time researchers had little knowledge as to why babies were dying. It wasn’t until the early 1990’s that bed sharing in relation to infants sleep environment was exposed as a risk factor (Das, Sanker, Agarwal & Paul, 2014). Bed sharing is defined as an adult (usually the mother) and their infant sleeping together in the same adult bed (Fetherston & Leach, 2012). This literature review critically looks at evidence to investigate why bed sharing happens and to explore the relationship between bed sharing and SIDS. This essay will also provide implications and recommendations in relation to the evaluation of evidence. SIDS was previously known as ‘Cot Death’ and more recently known as Sudden Unexpected Death in Infants (SUDI). However, throughout this literature review it will be referred to as SIDS.
Literature review evidence and findings
Bed sharing has been occurring for centuries and is closely associated with the promotion and continuation of breastfeeding (McKenna, as cited in Pemberton, 2005). Studies around bed sharing have concluded that bed sharing provides enhanced breast milk production, increased levels of bonding between the mother and infant and better maternal sleep (Homer, Armari & Fowler, 2012). Breastfeeding is recommended frequently as the best way to feed infants due to the numerous benefits it possesses such as; being a source of multiple necessary nutrients, protective mechanisms against diseases and it is a contributing factor in mother and infant bonding (Mitchell & Blair, 2012). In New Zealand health education is aimed to promote mothers to exclusively breastfeed their infants for the first six months of their lives (Plunket, 2014).
Despite numerous health campaigns and continued education concerning the risks associated with bed sharing, mothers continue to utilise bed sharing as a sleep strategy regardless of the risks involved (Homer et al., 2012). A study carried out by Homer et al. (2012) identified that 91.6% of the 1000 respondents (mothers) had difficulties when putting their infants to sleep, with 24% expressing that it was a regular struggle. The findings also show that almost half of the women in the study used sleeping while feeding as a sleep strategy (Homer et al., 2012). Exhaustion, tiredness and stress generated from sleep deprivation significantly influenced the mother’s decision to bed share with their infants. Furthermore, bed sharing was more likely to be used if infants frequently woke or were unsettled during the night (Homer et al., 2012). Ateah and Hamelin (2008) showed that although a percentage of the mothers appeared to be aware of some level of risk associated with bed sharing, those risks seem to be outweighed by the perceived benefits and convenience for example the practicality of feeding on demand throughout the night.
There is evidence that breastfeeding mothers who bed share adapt to the ‘C-shape’ sleeping position, which is said to facilitate breastfeeding and protect the baby from being rolled onto or moving in the bed; the ‘C-shape’ position is ‘…lying laterally facing the baby, with her upper arm above the baby’s head, and her knees drawn up under his or her feet’ (Pemberton, 2005, p.12). However, apposing evidence from Ateah and Hamelin (2008) study provides examples of situations by mothers who have experienced rolling onto their infants, this represents strong evidence of the reality of the risk involved with bed sharing.
Bed sharing and the risk of SIDS
There has been a significant decline in the incidences of infants dying from SIDS all over the world since in implementation of the ‘back to sleep’ campaign in the 1990s. Researchers have supported the fact that the most significant risk to infants dying unexpectedly was from them sleeping in the prone position. However, in New Zealand 45 infants die from SIDS each year, that’s approximately one in two thousand infants (SIDS New Zealand, 2008). In addition, it is the leading cause of death for children in New Zealand aged between one month and one year of age (SIDS New Zealand, 2008). Professor Mitchell reviewed 80 infant deaths in Auckland, New Zealand, where he found that 25% of babies died bed sharing. Mitchell then used that information to complete a study to determine if bed sharing was a risk or whether it reduced the risks of SIDS; he compared 393 cases with 1800 control families, which concluded and confirmed that bed sharing was a risk (Mitchell, as cited in Harries, 2012).
Although the aetiology by which bed sharing increases the risk of SIDS is unknown, research has suggested that the obstruction of infant airways, incidences of head covering, infants overheating and hypoxia due to re-breathing of expired gases are all possible mechanisms (Homer et al, 2012). When it comes to mother and infant bed sharing the primary concern portrayed through evidence is asphyxia of the infant.
One study by Ateah and Hamelin (2008) showed that 13% of the 212 respondents reported occurrences where either the mother herself or partner rolled onto or partway onto the infant for example ‘…I will occasionally fall asleep during feedings, she will move or fuss if I am ‘squashing’ her’ (p.279). Unintentional suffocation such as head covering has become an increased contributing factor to SIDS. The main dangers that are associated with head coverings are overheating, re-breathing of expired gases and an infant inability to arouse. In a study, Buddock et al. videotaped 40 infants and parents who regularly bed shared; recordings showed 102 incidences of head coverings. Furthermore, 80% of these head covering were due to change in sleep position of the mother (as cited in Harries, 2012).
Though evidence from research it has been recognised that smoking poses a risk of SIDS in infants. Infant exposer to tobacco smoke impairs their arousal mechanisms (Plunket, 2014), which in turn puts them in danger of SIDS because of their inability to respond to dangerous situations such as being accidentally suffocated. Bed sharing with a mother who smokes significantly increases the incidence of SIDS (Homer et al. 2012). An infant is 15 times more likely to die from SIDS when exposed to tobacco smoke, than their non-smoking counterparts (Pemberton, 2005). Some research proposes that there is no high risk existing if a mother who does not smoke bed shares with her infant. However, evidence by Carpenter et al., has shown that there is a risk associated with non-smoking mothers and bed sharing (as cited in Homer et al., 2012). As a result these findings suggest that all forms of bed sharing should be avoided.
Nurses should continue to educate mothers using the ‘SUDI message’ which is ‘to pursue safe sleep for every baby, every sleep, in every place they sleep’ (Cowan & Bennett, 2009, p.12). Additionally, portraying the following principles to promote the most protective sleep environment ‘face up, face clear, smoke free, in parents room’ (Cowan & Bennett, 2009, p.12). Through the use of communication nurses can also reassure mothers that it is normal that infants are easily aroused, need fed often and their need for cuddles (Cowan & Bennett, 2009). Co-sleeping in the same room, with the crib in close proximity to the mother (especially for the first six months) has been shown through research, to be not only beneficial for mothers who have difficulties with the frequent demand of breast feeding throughout the night but, in turn, this practice protects the infant from risks associated with bed sharing.
Overall, it is fundamental as nurses to respect the rights of mothers in the decisions they make regarding their infants. It is the nurses’ responsibility to fully inform mothers around the benefits, risks and risk factors that are associated with bed sharing, some of which are stated above, so that in turn they can make an informed choice (New Zealand Nursing Organisation, 2010).
It is difficult to control the safety of infants when they are bed share with mothers or other people due to the fact that people generally move during their sleep, bedding shifts and individual tiredness varies. It can also be a cultural or personal choice made my mothers to bed share with their infant. Therefore, the following are recommendations for the education to promote safe sleeping environments for infants, including infants in bed sharing situations to prevent SIDS from occurring.
Pepi-pods have contributed to the decline in rates of SIDS in New Zealand since 2011 when they were introduced following the earthquakes in Christchurch (Cowan, 2014). The use of Pepi-Pods when bed sharing with infants allows them to have a safe sleeping environment, protecting them from accidental suffocation and other factors in relation to sudden infant death whilst being in close proximity to their mothers.
To ensure safe sleeping for infants the following should recommended by all health professionals: Pillows should be kept away from the baby, mattress should be firm, ensure that there are no gaps that the baby could become trapped in, maintaining room temperature around 18 degrees, infant be placed face up, face clear and have a smoke-free environment (Plunket, 2014). Following these recommendations will minimize the mechanisms that can be associated with SIDS for example asphyxia, over heating and accidental head coverings.
In conclusion, while some research has shown that bed sharing aids in the facilitation of breastfeeding, others have identified it as a risk for sudden infant death syndrome. It is evident that bed sharing poses a risk of SIDS, with the primary concern being asphyxia. It may be that SIDS is never eradicated, however, with the use of education around the benefits and risks associated with bed sharing mothers are fully informed to make the best decision they see fit in regards to their infants.
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Cowan, S. (2014). Pepi-pods contribute to safe sleeping for babies. Kai Tiaki Nursing New Zealand, 20(2),9.
Cowan, S., & Bennett, S. (2009). Pursing safe sleep for every baby, every sleep, in every place they sleep. Kai Tiaki Nursing New Zealand, 15(6),12-13.
Das, R. R., Sanker, M. J., Agarwal, R., & Paul, V. K. (2014). Is “Bed Sharing” Beneficial and Safe during infancy? : A systematic review. International Journal of Pediatrics, 56(1),1-9. doi: 10.1155/2014/468538
Fetherston, C.M., & Leach, J. (2012). Analysis of the ethical issues in the breastfeeding and bed sharing debate. Breastfeeding Review, 20(3), 7-17.
Harries, C. (2012). Bed sharing Is it worth the risk?. Community Practitiner, 85(11), 14-15.
Homer, C., Armari, E., & Fowler, C. (2012). Bed-sharing with infants in a time of SIDS awareness. Neonatal, Paediatric & Child Health Nursing, 15(2), 3-7.
Mitchell, E. A., & Blair, P. S. (2012). SIDS prevention: 3000 lives saved but can we do better. The New Zealand Medical Journal, 125(1359), 1-8.
New Zealand Nurses Organisation. (2010). Code of ethics. Wellington, New Zealand: Author.
Pemberton, D. (2005). Breastfeeding, co-sleeping and the prevention of SIDS. British Journal of Midwifery, 13(1),12-18.
Plunket. (2014). Sudden unexpected death in infancy. Retrieved from https://www.plunket.org.nz/your-child/welcome-to-parenting/sudden-unexpected-death-in-infancy-sudi/
SIDS New Zealand. (2008). Facts and Figures. Retrieved from http://sids.org.nz/site/content/information/health_facts_and_figures/