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Estimated reading time: 11 minutes
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Estimated reading time: 11 minutes


Weaver Features
Updated November 2016
Diane Wiessinger, Diana West, Linda J. Smith, Teresa Pitman
Photo: Weaver by Lisa on Location Photography

 

Sweet Sleep book advertisementExcerpted from Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family, Chapter 2: The Safe Sleep Seven, by Diane Wiessinger, Diana West, Linda J. Smith, Teresa Pitman, a La Leche League International book, Ballantine Books, 2014.

Wah! Wah! Wah! Drag yourself out of your nice cozy bed, pick up your screaming baby, sit down to nurse, try to stay awake, put him back in the crib, stagger back to bed, and hope, hope, hope he stays asleep for at least two hours. I had no idea I could feel that exhausted. I could not understand how other mothers survived this, because I didn’t think I was going to.

My friend who’s a La Leche League Leader came over and saw how worn down and bleary-eyed my husband and I looked. She asked if we’d thought about bedsharing to get more sleep. No. Not for us. Never. But she laid out seven things that make it safer. That night, out of pure desperation and sleep deprivation, I brought my son into my bed for part of the night . . . and I started the next day a bit brighter. He spent more and more time in my bed at night, and lo and behold, we both got more and more sleep. —Monica

Today’s culture says you should keep the baby in your room… but not in your bed. Feed him in bed and get really drowsy…but then get out of bed again. Two trips out of bed for every feeding. By about six weeks, something has to give. (1) Weaning? Leads to short-term and long-term problems. (2) Night weaning? Not healthy for you, your baby, or your milk supply at this age. (3) Supplementing? Ditto. (4) Break out the sleep-training book from the baby shower? Not as harmless as it seems (see Chapter 18).

A mother’s first step is usually to find a place where she can relax for night feedings. The American Academy of Pediatrics (AAP) says, “Infants may be brought into the bed for feeding or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep.” (5) Easy to say. When most of us are “ready to return to sleep,” steeped in hormones that make us sleepy, the last thing we want is to get up again. If a mother’s afraid to nurse in her own bed, her most likely options are a sofa, recliner, or upholstered chair—all riskier places to sleep with a baby. One study found that 44 percent of mothers who nurse in those places at night fell asleep there at least once. (6) Eventually, many mothers find that bedsharing is a low-risk, long-term solution for sleep deprivation and an unhappy baby. (7) But they often go through several high-risk arrangements along the way.

The Safe Sleep Seven Bedsharing Song

(to the tune of “Row, Row, Row Your Boat”)

No smoke, sober mom

Baby at your breast

Healthy baby on his back

Keep him lightly dressed.

courtesy Diana West

courtesy Diana West

Not too soft a bed

Watch the cords and gaps

Keep the covers off his head

For your nights and naps.

Even though most new breastfeeding mothers today don’t plan to bedshare, studies show that eventually 60 to 75 percent of them will, at least some of the time. (8) Why? Probably because most breastfeeding mothers get more sleep when they bedshare. (9) In fact, a lot of mothers who say they don’t bedshare actually do. If the baby starts the night in the crib, if the baby started the night in the crib last night, if the baby usually comes into his mother’s bed at the first waking, even if a family simply owns a crib . . . any of those can lead a mother to say—and believe—that she doesn’t bedshare when she actually does. (10)

One of the big reasons that bedsharing is safer when you’re breastfeeding is the way you position your body next to your baby. During sleep, you’ll automatically go into the same position as breastfeeding mothers all over the world and throughout time. It’s called a cuddle curl, and it’s nature’s way of protecting a baby during sleep. Your knees come up and your arm tucks under your head or pillow, or curls around your baby, creating a protected space. There’s no way for you to roll toward your baby because your bent legs won’t let you. And no one else can roll into the space because your knees and elbows are in the way. (11) Very cool! (If you’re worried about your partner, just sleep between your partner and the baby.)

Even during sleep a breastfed baby will instinctively stay with his face near the breast, because that’s the center of his universe (and his kitchen). (12) If your baby homes in on your breast, he’s not going to wander up into the pillows or down under the covers (and your arm and legs won’t let him).

There’s another layer of protection too: normally, we’re aware of the edges of our bed and the bodies of our pets, even when we’re sound asleep. We don’t roll over on a baby any more than we roll off the side of the bed or roll over on the cat. And of course both the cat and the baby would react if you tried.

A mother who has never breastfed loses some of these protections. She tends to move her baby closer to her own face, where those puffy, smothery pillows are. (13) And a baby who doesn’t breastfeed is more likely to wander up there himself, even if the bottles are filled with his mother’s milk.

What if you’re still working out the kinks, maybe pumping for a baby who isn’t nursing yet? A newborn will automatically seek his mother’s breast. If you’ve been focused on helping him breastfeed, you’ll probably find yourself doing a cuddle curl, at least at first.

If you breastfeed most of the time but give occasional bottles of pumped milk, you’ll probably still sleep in a breastfeeding cuddle curl, and your baby will most likely stay at chest level. (14) But if either of you sees a bottle as the more important food source, you and your baby may not automatically “think breast,” and your bedsharing risk may increase. (15) If you’re just not sure, think carefully about how you cradle your baby when you lie down, and maybe have your partner watch how you interact before you decide for or against bedsharing.

What if your baby gets formula sometimes? Exclusive formula-feeding increases the risk of SIDS (see Chapter 19); partial formula-feeding is a smaller SIDS risk.

By about four months, any responsible adult can bedshare as safely as a responsible breastfeeding mother. (16)

For those who say they don’t need to prepare their bed for bedsharing because they’ll never, ever do it, think about car accidents. No one ever expects them to happen either. But they do. That’s why we wear seat belts. It’s not that we’re planning to have an accident; it’s that accidents are never planned. So we plan ahead, and we don’t give it another thought. Simple and safe—or as safe as being in a car can get.

A planned-ahead bed is just a seat belt. Then at 3:00 a.m. when your baby just can’t sleep alone even though you’ve tried everything up, down, and sideways, you can collapse in bed with your baby and stay there snugly until morning. Tomorrow morning you can decide what you want to do tomorrow night. Life is risky, no matter how you live it. A safe bed, like a seat belt, can greatly reduce that risk.

The Key Points for Safe Sleep for All Babies

Stay smoke-free. Stay sober. Stay off sofas, upholstered chairs, and recliners for sleep. Keep your healthy baby lightly dressed, on his back, and near you for sleep. And, of course, keep breastfeeding.

But what about all the warnings against bedsharing? If you meet the criteria outlined in the Safe Sleep Seven, then you’re not the mother the warnings are for! Only a small subset of babies with certain preexisting vulnerabilities is at risk for SIDS. The risk for SIDS or suffocation is far, far, far greater in a household where the mother smokes, where alcohol or drugs are involved, where the baby is formula-fed, or in truly chaotic settings where the baby sleeps who knows where or with who knows whom (see Chapter 19). In an attempt to reach certain mothers and protect certain babies, the warnings have been made very clear, very strong, and very simple. The answers for you are just as simple.

The Key Points for Applying the Key Points

Every situation is different. Life is never 100 percent safe. And everyone balances risk and benefits differently. Take the information we present and use your mother-wisdom to decide what’s best for you, your baby, and your family.

All those scary warnings are about only the first four months. Beyond that? Even the researchers behind the bedsharing cautions agree that by about four months bedsharing by any responsible, nonsmoking adult is as safe as having your baby sleep separately in a bassinet or crib. (11)

If you and your baby fit the Safe Sleep Seven criteria, your baby’s risk of SIDS is what one sleep researcher calls vanishingly small. And you’ll virtually eliminate overlying and other suffocation risks.

The Safe Sleep Seven

If you are:

1. A nonsmoker
2. Sober and unimpaired
3. A breastfeeding mother and your baby is:
4. Healthy and full-term
5. On his back
6. Lightly dressed
and you both are:
7. On a safe surface

Then your baby in bed with you is at no greater risk for SIDS than if he’s nearby in a crib. The Safe Surface checklist explains number 7 and practically eliminates breathing risks no matter where he sleeps. Rolling over on your baby is virtually impossible because you have the cuddle curl (see above) and responsiveness of a breastfeeding mother. By the time the baby is about four months old, research indicates that bedsharing with a healthy baby by any responsible nonsmoking adult on a safe surface is as safe as any other sleep arrangement.

 Safe Sleep Seven Infographic

The Safe Surface Checklist

Avoid these possible smothering risks:

  • Sofas and recliners
  • Softness or sagging that rolls your baby against you or keeps him from lifting his head free
  • Spaces between mattress and headboard, side rails, or wall where a baby could get stuck
  • Pets that could interfere

Clear your bed of:

  • Unused pillows
  • Stuffed toys
  • Heavy covers and comforters
  • Anything nearby that dangles or tangles (such as cords, strings, scarves, ribbons, elastics)

Check your bed for possible hazards:

  • Distance to floor
  • Landing surface
  • Sharp, poking, or pinching place

The remainder of Chapter 2 explores the details of each Safe Sleep Seven criteria, including the research and common sense behind them.

Something to Sleep On

Research on infant sleep risks, which we go over in depth in Chapter 19, shows again and again that the big risks of shared sleep are a mix of SIDS risks that affect vulnerable babies and breathing hazards that affect all babies: smoking, alcohol or drugs, risky surfaces like sofas, baby on his front (unless he’s on an adult’s chest), and formula-feeding. Combine two or more of those, and the risk can skyrocket.

If you and your baby meet the requirements in the Safe Sleep Seven checklist, you’ve already eliminated all the biggest SIDS risks. And if you prepare your bed, then your baby’s overall nighttime risk becomes vanishingly small. It’s like putting your seat belt on and then driving slowly on a deserted (and lovely!) country road. Enjoy having your baby beside you for the journey.


 References

1 Ball, H. L. Breastfeeding, bed-sharing, and infant sleep. Birth 30, no. 3 (2003): 181–188. Ball, H. L., Hooker, E., Kelly, P. J. Where will the baby sleep? Attitudes and practices of new and experienced parents regarding cosleeping with their newborn infants. American Anthropologist 101, no. 1 (1999): 143–151.

2 U.S. Department of Health and Human Services. Executive summary: the surgeon general’s call
to action to support breastfeeding. Breastfeeding Medicine 6, no. 1 (2011): 3–5.

3 Imong, S. M., Jackson, D. A., Wongsawasdii, L., et al. Predictors of breast milk intake in rural northern Thailand. Journal of Pediatric Gastroenterology and Nutrition 8, no. 3 (1989): 359–370. Kent, J. C. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics 117, no. 3 (2006): e387–e395.

4 Howel, D., Ball, H. Association between length of exclusive breastfeeding and subsequent breastfeeding continuation. Journal of Human Lactation 29, no. 4 (2013): 579–585.

5 Moon, R. Y., et al. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 128, no. 5 (2011): e1341–e1367.

6 Kendall-Tackett, K., Cong, Z., Hale, T. W. Mother- infant sleep locations and nighttime feeding behavior. Clinical Lactation 1, no. 1 (2010): 27–30.

7 Colson, E. R., Willinger, M., Rybin, D., et al. Trends and factors associated with infant bed sharing, 1993–2010. The National Infant Sleep Position Study. JAMA Pediatrics 167, no. 11 (2013): 1032–1037.

8 Ball, H. L. Breastfeeding, bed-sharing, and infant sleep. Birth 30, no. 3 (2003): 181–188. Ball,
H. L. Bed-sharing practices of initially breastfed infants in the first 6 months of life. Infant and Child Development 16, no. 4 (2007): 387–401.

Ball, H. L. Reasons to bed-share: why parents sleep with their infants. Journal of Reproductive and Infant Psychology 20, no. 4 (2002): 207–221.

Kendall-Tackett, K., Cong, Z., Hale, T. W. Mother- infant sleep locations and nighttime feeding behavior. Clinical Lactation 1, no. 1 (2010): 27–30.

Lahr, M. B., Rosenberg, K. D., Lapidus, J. A. Maternal-infant bedsharing: risk factors for bedsharing in a population-based survey of new mothers and implications for SIDS risk reduction. Maternal and Child Health Journal 11, no. 3 (2007): 277–286.

Blair, P. S. The prevalence and characteristics associated with parent-infant bed-sharing in England. Archives of Disease in Childhood 89, no. 12 (2004): 1106–1110.

9 Quillin, S. I. M. Interaction between feeding method and co-sleeping on maternal-newborn sleep. Journal of Obstetric, Gynecologic, and Neonatal Nursing 33, no. 5 (2004): 580–588.

10 Ball, H. L., Hooker, E., Kelly, P. J. Where will the baby sleep? Attitudes and practices of new and experienced parents regarding cosleeping with their newborn infants. American Anthropologist 101, no. 1 (1999): 143–151.

11 Ball, H. Parent-infant bed-sharing behavior. Human Nature 17, no. 3 (2006): 301–318.

Ball, H. L., Klingaman, K. Breastfeeding and mother- infant sleep proximity. In Trevathan, W. R., Smith, E. O., McKenna, J. J. (eds.), Evolutionary Medicine. New York: Oxford University Press, 1999.

12 Richard, C., Mosko, S., McKenna, J., et al. Sleeping position, orientation, and proximity in bedsharing infants and mothers. Sleep 19, no. 9 (1996): 685–690.

Baddock, S. A., Galland, B. C., Bolton, D. P. G., et al. Differences in infant and parent behaviors during routine bed sharing compared with cot sleeping in the home setting. Pediatrics 117, no. 5 (2006): 1599–1607.

13 Ball, H. Parent-infant bed-sharing behavior. Human Nature 17, no. 3 (2006): 301–318. Ball, H. L., Klingaman, K. Breastfeeding and mother-infant sleep proximity. In Trevathan, W., Smith, E. O., McKenna, J. J. (eds.), Evolutionary Medicine and Health: New Perspectives. Oxford: Oxford University Press, 2008.

14 Ball, H. Parent-infant bed-sharing behavior. Human Nature 17, no. 3 (2006): 301–318. McKenna, J. J., Ball, H. L., Gettler, L. T. Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: what biological anthropology has discovered about normal infant sleep and pediatric sleep medicine. American Journal of Physical Anthropology 134, suppl. 45 (2007): 133–161.

15 Volpe, L. E., Ball, H. L., McKenna, J. J. Nighttime parenting strategies and sleep-related risks to infants. Social Science and Medicine no. 79 (2013): 92–100.

16 Blair, P. S., Fleming, P. J., Smith, I. J., 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 319, no. 7223 (1999): 1457–1461. Carpenter, R. G., Irgens, L. M., Blair, P. S., et al. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet 363, no. 9404 (2004): 185–191. Tappin, D., Ecob, R., Brooke, H. Bedsharing, roomsharing, and sudden infant
death syndrome in Scotland: a case-control study. Journal of Pediatrics 147, no. 1 (2005): 32–37. Vennemann, M. M., Bajanowski, T., Brinkmann, B., et al. Sleep environment risk factors for sudden infant death syndrome: the German Sudden Infant Death Syndrome Study. Pediatrics 123, no. 4 (2009): 1162–1170. Ruys, J. H., De Jonge, G. A., Brand, R., et al. Bed sharing in the first four months of life: a risk factor for sudden infant death. Acta Paediatrica 96, no. 10 (2007): 1399–1403. Moon, R. Y., et al. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 128, no. 5 (2011): e1341–e1367.

Resources

Infant Sleep

In the Still of the Night

Nighttime Parenting:Baths, Boobies & Bedsharing

Should I Night Wean?

NEW November 2016 UNICEF Co-Sleeping and SIDS: A Guide for Health Professionals


Comments

  1. […] The Safe Sleep Seven – Breastfeeding Today. The remainder of Chapter 2 explores the details of each Safe Sleep Seven criteria, including the research and common sense behind them. Something to Sleep On Research on infant sleep risks, which we go over in depth in Chapter 19, shows again and again that the big risks of shared sleep are a mix of SIDS risks that affect vulnerable babies and breathing hazards that affect all babies: smoking, alcohol or drugs, risky surfaces like sofas, baby on his front (unless he’s on an adult’s chest), and formula-feeding. Combine two or more of those, and the risk can skyrocket. If you and your baby meet the requirements in the Safe Sleep Seven checklist, you’ve already eliminated all the biggest SIDS risks. References 1 Ball, H. 2 U.S. 3 Imong, S. 4 Howel, D., Ball, H. 5 Moon, R. 6 Kendall-Tackett, K., Cong, Z., Hale, T. 7 Colson, E. 8 Ball, H. […]

  2. […] WHAT). A good source of information is Sweet Sleep with a preface by Helen Ball. Read an excerpt here and watch LLLI Sweet Sleep Author […]

  3. […] The Safe Sleep Seven […]

  4. […] The Safe Sleep Seven: Nighttime strategies […]

  5. […] The Safe Sleep Seven: Nighttime strategies […]

  6. […] The Safe Sleep Seven […]

  7. […] At Durham University’s Parent-Infant Sleep Lab we have been instrumental in researching how parents and babies co-sleep, so this was an error we could not ignore! In posting an online response about the picture, we explained why positioning this image under the headline “Making informed choices on co-sleeping with your baby” was particularly ironic, and why it was important for all media—not just medical journals—to model safer bedsharing in their illustrations. The link between SIDS and prone sleeping has been the focus of SIDS reduction campaigns since the nineties, as has guidance to parents to avoid having their babies sleep on pillows and other suffocation hazards. One of the informed choices parents should be making when they opt to co-sleep is how to do so as safely as possible (and not as depicted by the BMJ)! See The Safe Sleep Seven. […]

  8. […] read more about how to sleep safely, see The Safe Sleep Seven. You can read more about infant sleep, bedsharing, and nighttimes on Breastfeeding […]

  9. […] for SIDS and Hip Dysplasia. I couldn’t do it any longer. So I tucked my son next to me on a safe bed surface in the instinctual cuddle curl  that mothers have been using for thousands of years and I slept. […]

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