Mixed messages: Where should babies sleep?

The Pediatric Insider

© 2017 Roy Benaroch, MD

A new study about the best place for babies to sleep – in their own rooms, or sharing a room with their parents – contradicts current AAP guidelines. But hopefully, in the long run, it will help more parents and babies get a better night’s sleep overall.

The most recent “safe sleep” guidelines were published in 2016. They stressed evidence-based recommendations for the safest way for babies to sleep: put down on their backs for every sleep, and on a firm, flat surface. Since bed sharing is has been shown to increase the risk of SIDS (especially in younger babies), it was also recommended that babies sleep on their own surface, designed for infants. And babies were supposed to sleep in their parents’ bedroom for at least the first six months of life, and ideally for 12 months.

It’s that last recommendation that I’ve never been completely happy about. The recommendation is based on three studies from the 1990s, all from Europe (where almost all babies slept in parents’ rooms, and, at the time, on their tummies.) In the aggregate, these studies showed fewer SIDS cases in babies sharing a room with their parents. But: there were very few SIDS cases to compare, and the one study that separated out babies by age at death showed that babies less than 4 months were safer in their own rooms (and less than 4 months is the peak time for SIDS.)  So the evidence, then, wasn’t very strong – but it was the best evidence at the time, and the AAP decided the “share room with parents” idea deserved to be a recommendation.

I also think the Academy was swayed by room sharing’s making nursing easier, which is true. Breastfeeding is associated with a decreased SIDS risk.

The “ideally until 12 months” part of the recommendation was especially problematic. SIDS rates are very low past 6 months, making conclusions about the effect of sleeping location for older infants tenuous at best. 12 months is also peak time for separation anxiety, and a terrible time to first put your child alone to bed. The AAP decided to extend the “ideal time” in parents’ room to 12 months to be extra cautious, but I’m not sure they considered the overall burden this could place on many parents and children in terms of overall quality of life.

Now, a new study throws a wrench into this “same room” recommendation. Researchers tracked the sleep habits of babies who slept in their parents’ rooms, versus their own rooms, and the results aren’t terribly surprising. Room sharing at 4 and 9 months is associated with less sleep for babies, and fewer long stretches of sleep. Babies seem less able to “consolidate” or organize their sleep into longer stretches if they’re sharing a room with parents. And: room sharing makes it more likely that babies will end up in known unsafe sleep positions – like sleeping directly in their parents’ beds. But wasn’t room sharing supposed to be safer?

It’s a mixed message, but it reflects that the evidence for this room sharing recommendation has never been very strong. With this new study, parents should feel more comfortable, and less guilty, if they choose to put babies in their own rooms to sleep.

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9 Comments on “Mixed messages: Where should babies sleep?”

  1. Angela Says:

    We put our first two babies in their own rooms from day 1. With our third we tried out room sharing. By six weeks he was in his own room, and we all slept so much better! We’re done having babies, but I would not room share again. Newborns are noisy, fidgety sleepers!

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  2. Alexis Says:

    What frustrates me in almost all studies is the #1 predictor (especially of older babies) in sleep quality and duration is how they fall asleep. I suspect (no citations, just my experience) that parents who move children to their own rooms are more likely to have established independent sleep at bedtime. And if I’m right (who knows really) THAT would be the key driver in the delta of sleep duration.

    I would also be curious to know more about parent sleep quality. Because babies make terrible roomates (as Angela mentions) and its hard to sleep well when your roomate is grunting and fidgeting all night.

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  3. dm Says:

    When is the AAP and pediatricians as a profession in general going to have some serious self-reflection about the evidence base for recommendations? By making recommendations that place significant burdens on parents without the actual scientific basis, they’re just going to make parents STOP listening to them when it comes to the actually important things, like vaccinations. Trust is important when it comes to medical advice. Not to mention the whole scandal of the AAP CREATING peanut allergies through faulty recommendations …

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  4. Dr. Roy Says:

    dm, I hear ya. And believe me, at the national meetings there are colorful, noisy, contentious discussions of these very issues. Not all peds are in lockstep w/ the AAP.

    Though I will say that overall the AAP does do a good job of providing good, evidence-based recommendations — though they can only reflect the evidence that’s available at the time. The earlier recommendations to delay the introduction of solids (like peanuts) were informed by previous bench and clinical studies that didn’t hold up to better research. That doesn’t mean they were wrong at the time they were written (well, they were, but there was no way of knowing it.)

    AAP recommendations do typically include an assessment of the quality of the evidence, but I admit we (pediatricians) aren’t very good at communicating that when we talk to parents. That’s a very good point — we need to be more transparent about just how good the evidence is for our recommendations. In the case of room sharing as a SIDS preventive past age 6 mos, the evidence had been, well, almost nonexistent; even prior to 6 mos I don’t think it was compelling, and I wouldn’t have included that in the 2016 recommendations.

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  5. As the mother of a seven month old son, who is still sleeping in our bedroom (in his Pack n Play) it’s interesting to hear your spin on this! I’m very nervous to move him but also a little desperate for longer sleep stretches. He’s also taken to rolling over on his tummy for sleep, which adds to the nerves. Maybe I’ll be less nervous when he’s 30!

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  6. akw62307 Says:

    When my daughter was born (2.5 years ago) she slept in a bassinet on her back for the first 6-7 weeks and then we moved her to her crib and I slept much better personally because I didn’t stay awake constantly looking over to see if she was breathing. With my son, he stayed in the bassinet in our room to 10 weeks and then moved to his crib. Both were sleeping long stretches when moved and would go right back to sleep when waking for a night feed. I refused to co-sleep as it made me nervous and always follow safe sleeping practices when they were in their bassinet or cribs. I think by transitioning them early it helps avoid any issues we would have with separation anxiety later on trying to move them to individual rooms.

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  7. Dr. Roy Says:

    andthewind, once babies can roll over there should be no added worries — the safe sleep guidelines have never suggested you have to KEEP babies on their backs, just that you’re supposed to put them down that way. Let rollers roll!

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  8. Rachel Says:

    Our nine babies slept in our room and were nursed in my bed. I will never regret that closeness. I’m guessing there is a lot more involved in SIDS than the sleeping arrangement. Smoking, diet, tension and stress etc.

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  9. The AAP insists on evidence, but the pediatricians for my clients seem to have no concept of what actually helps newborns (or older babies) sleep well or longer. Safe is great, but a screaming infant at 3 am creates a situation where statistics and blanket statements aren’t that meaningful to parents! Parents see firsthand that back-to-sleep without swaddling makes it harder for newborns to calm themselves, so co-sleeping in the parent’s bed looks successful… because it is. It just raises the risk of SIDS in the youngest infants and sets kids up without any self-calming strategies. What’s a parent to do at night? Wait for research, or do what seems to work? They are exhausted and hormone-affected.
    No wonder so many pediatrician’s fall back on that stupid “purple period” idea that you just tough it out and nothing can be done. If all you have is a hammer, everything you see is a nail.

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