One of the stories in the press this week was a scary one for new parents and the professionals who support them:  sleeping with a newborn baby endangers their life.  I thought it important to write a piece on this story because the press coverage made it sound as if this is now an issue that has been firmly decided.  That impression is easily gained through headlines such as the BBC’s ‘Bed sharing “raises cot death risk fivefold,”’ the NHS’s ‘Sharing a bed with your baby ups risk of cot death’ and the Telegraph’s ‘Sharing bed with babies raises cot death risk’.

However, there is a debate taking place amongst scientists and many family support organisations, much of which has not made it into the mainstream media.  Being aware of that debate helps parents and professionals to be more informed and thus more confident about the decisions parents take regarding their style of parenting.  Awareness of that debate also helps to make sense of any apparent conflict that exists between this advice and the broader understanding we are gaining about the attachment processes of infancy.

This recent bout of attention to infant sleeping stems from a new scientific paper, written by a team led by Professor Robert Carpenter of the London School of Hygiene and Tropical Medicine and published in the British Medical Journal Open.  In this paper, which is available for download to the public, the authors review a set of 19 earlier studies on sleeping arrangements of infants, looking particularly at data sets that report on sudden and unexplained infant deaths [SIDS].  The recommendation that the authors make on the basis of their analysis is that parents should always avoid sleeping with their newborn infants.  “Our findings suggest that professionals and the [scientific] literature should take a more definite stand against bed sharing, especially for babies under 3 months.”  (page 10).

However, some important commentators have expressed reservations about this inflexible, blanket stance.  I think it is valuable to draw attention to these comments, so that it is clear that a debate remains about this issue.  Such awareness encourages us all to become more curious about the complexities of scientific investigation, and I hope reduces parents’ and professionals’ fear.   I am concerned about the way in which media stories often feed fear.  Raising children on the basis of fear is not good for anyone.

The UNICEF UK Baby Friendly Initiative produced a response to the study that includes the following statements:

The impression from the press release is that infants in the general population are at a 5-fold risk of SIDS when the parents bed-share and don’t smoke, which is untrue….There is strong evidence that breastfeeding and bed-sharing have an interdependent relationship, and the issue of what to discuss with parents regarding parent-infant bed sharing is controversial and confusing.  Bed-sharing has advantages and dangers, and views are informed by culture and personal belief.  UNICEF UK’s recommendations to health professionals on the key information that should be discussed with all parents in order to protect babies…will not be changing in the light of the limited findings from this paper.

Radio 4’s evening news programme, PM, hosted a respectful discussion on 21^st May between Professor Carpenter and Professor Helen Ball, who runs the Parent-Infant Sleep Lab at Durham University.  In that interview, which is available on Listen Again (at Minute 37) until 28 May, Professor Ball said:

I want to begin by saying that I appreciate that Professor Carpenter and his colleagues have done this piece of work, because it is something that we have been hoping that someone with the relevant data set would do, for quite a long time, because it is one of the questions that parents always ask.  However, we do have a problem with some of the conclusions that the paper has drawn, particularly the one suggesting that parents should be told not to bed share.  This seems to be a rather large leap from the small risk that the paper is talking about.

The Infant Sleep Information Source, which is a collaborative initiative between organisations such as the Parent-Infant Sleep Lab, UNICEF, La Leche League, and the NCT, published a written response to the study in which they expressed concern about the “weak evidence” that the study uses as the base for proposing public health policy on parental infant care. That response includes the following:

The recommendations of the authors that parents are advised to ‘simply avoid bed-sharing’ indicates a worrying lack of cultural awareness or sensitivity to childrearing beliefs of different groups of parents on the part of these SIDS researchers.  Such a recommendation does not allow parents, especially those whose infants are at a low risk for SIDS, to make an informed choice to bed-share or not.  Single message recommendations…are inappropriate and ineffective for addressing infant care issues involving relational behaviours and cultural beliefs.

This last comment contains within in it a term that is of particular significance for me:  ‘relational behaviours’.  Sleeping is a relational activity for babies.  That means that babies’ ability to do it is affected by the way they are relating to other people in their world.  This may be a surprise for many people.  It is easily possible to remain unaware of just how much of a baby’s behaviour, including fundamental bodily functions, are shaped by their experiences of other people.  Yet this is what the emerging evidence about attachment processes is teaching us:  that every activity in which a baby human being engages is shaped by that baby’s relationship with his/her key caregivers.

I want to stress that the study conducted by Professor Carpenter and his colleagues was not poorly done.  The debate that has emerged is not about the quality of the empirical work.  The debate is about what conclusions it is appropriate to draw from the work.  This is the nature of all science; scientists have to decide what interpretations they feel can be draw from their analyses.  Not everyone agrees about the interpretations that this scientific team has made in this case.

Professor Ball and others are arguing that it is important to balance interpretations is because there are many benefits that come from sleeping with babies, benefits that have very positive impacts on development.   Research shows that these include extended breast-feeding, correspondence in mother-infant heart and breathing rates, more sleeping on the back rather than the tummy, synchronous sleep cycles between mother and baby, and much more touch and interaction.  All of these benefits boost infant development, and they are factors encouraged by health professionals.  So these need to be considered alongside any decrease that is associated with arrangements where babies sleep elsewhere.  The experiences of parents who choose to co-sleep are helpful in thinking through that balance.

Moreover, Professor Ball points out that the risk identified in the study is very small: in the order of magnitude of 1 in 10,000 babies, and that it does not apply equally across all babies and families.   Families in which parents smoke have a much higher risk of SIDS, for example.  So she and her colleagues do not want parents simply to be told what to do.  They want to boost the level of information and knowledge parents have, and to empower parents in making decisions about themselves and their children. This is because, as the response paper from the Infant Sleep Information Source goes on to state, there are further risks at stake when knowledge and empowerment is not the goal:

Closing down all discussion of the reasons why parents might bed-share with their infant by issuing a dogmatic recommendation inhibits health professionals from raising the topic, causes parents to lie about their behaviour, and stifles the provision of information about hazardous sleeping environments and the degrees of risk involved.

I agree with Professor Ball’s caution.  I hear all the time from parents who tell me, confidentially, about their struggles in getting their babies to sleep.  They tell me about how they have lied to health visitors when they ‘resorted’ to taking their baby into bed, and how they felt guilty and disappointed by their ‘failure’ to ‘get their baby to do’ what their health visitor or the book author had suggested.  Understanding the fundamental relational basis of all babies’ behaviour helps us to make sense of these parents’ struggles.  It is hard for babies to sleep alone.  Their relational nature means they weren’t physiologically designed to do this.  Thus, understanding the relational nature of infant behavior helps parents to feel less confused, worried, and guilty.  They can relax and become more curious about what their baby is telling them, which lets them take more confident decisions about how they can best parent their child.

An excerpt from the recent book by Professor Jared Diamond, called ‘The World Until Yesterday’,  gives a historical and global context within which we can place babies’ sleep struggles.  His book explores lessons that can be learned from traditional societies:

In every known society of hunter-gatherers and of higher primates, mother and infant sleep immediately nearby, usually in the same bed or on the same mat.  A cross-cultural sample of 90 traditional human societies identified not a single one with mother and infant sleeping in separate rooms: that current Western practice is a recent invention responsible for the struggles of putting kids to bed that torment modern Western parents.  American paediatricians now recommend not having an infant sleep in the same bed with its parents, because of occasional cases of the infant ending up crushed or else overheating; but virtually all infants in human history until the last few thousand years did sleep in the same bed with the mother and usually also with the father, without widespread reports of the dire consequences feared by pediatricians.  That may be because hunter-gatherers sleep on the hard ground or on hard mats; a parent is more likely to roll over onto an infant in our modern soft beds.  (pg. 184)

All parents want to keep their children safe.  That is why coverage of this debate is so important and why it goes to the heart of all new parents’ concerns.  The pain of having a baby die due to unexplained circumstances is agony.  Everyone entering into this debate keeps this loss at the forefront of their minds.

This is why my central point is that to keep our babies really safe, and to help them reach their greatest potential, we need always to incorporate an understanding of attachment processes.  We must understand that every single one of a baby’s behaviours are relational – from their sleeping to their crying to their very heart rate.  Babies’ physiology has been designed by evolution to be tied to other people — because human babies depend on other people for their survival.  This relational perspective gives us a more informed context within which parents can take complex decisions about how best to care for their babies and within which professionals can take decisions about how best to advise parents.

It seems that, on the basis of Professor Carpenter’s paper, the Government may shortly undertake an “urgent review” of guidance on sleeping.  I hope they will keep our now robust knowledge about the relational needs of babies in the forefront of their mind as they undertake that review.