Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6, Revision 2019

Summary

Levels of evidence (1–5) from the Oxford Centre for Evidence Based Medicine are listed in parentheses, and are based on the citations are described below in the supporting material. See the supporting material for the ways in which we define “bedsharing,” “SIDS,” and “separate sleep” for purposes of this protocol. “Breastsleeping” is defined there as well.

Overall, the research conducted to date on bedsharing and breastfeeding indicates that nighttime proximity facilitates breastfeeding duration and exclusivity (levels 2–3). Discussions about safe bedsharing should be incorporated into guidelines for pregnancy and postnatal care. Existing evidence does not support the conclusion that bedsharing among breastfeeding infants (i.e., breastsleeping) causes sudden infant death syndrome (SIDS) in the absence of known hazards (level 3) (see Table 1 ). Larger studies with appropriate controls are needed to understand the relationship between bedsharing and infant deaths in the absence of known hazards at different ages. Not all hazards are individually modifiable after birth (e.g., prematurity). Accidental suffocation death is extremely rare among bedsharing breastfeeding infants in the absence of hazardous circumstances (levels 2–3), and must be weighed against the consequences of separate sleep. There are consequences to breastfeeding with separate sleep (even with room-sharing) that include the risk of early weaning, the risk of compromise to milk supply from less frequent nighttime breastfeeding, and unintentional bedsharing (levels 1–3). Recommendations concerning bedsharing must take into account the mother’s

Recommendations

All families should be counseled about safe sleep. Table 2 summarizes safe sleep advice in order of importance based on the strength of the evidence. In addition, we recommend the following:

• 1.

  Discussion with open-ended questions from health care providers concerning bedsharing safety should happen with all parents, as bedsharing is likely to happen whether intended or not (level 4). These discussions should take place early in the perinatal course and continuously throughout infancy, and include as many caregivers as possible. Open-ended questions that have been found to be successful in opening conversations include:

  • a.

    “What are your plans for where your baby will sleep?”

  • b.

    “What does that sleep area look like?”

  • c.

    “Does your baby ever end up in bed with you?”

• 2.

  Screen families at increased risk of infant death with bedsharing: infants who were born preterm (level 2) (level 3), exposed to tobacco antenatally (level 1) (level 4) (level 5), live with smokers (level 1) (level 3) (level 4), and those who live with people who consume alcohol (level 3) or drugs and, therefore, might be in charge of an infant and could fall asleep with the infant.

• 3.

  Information and counseling about safe bedsharing should be provided even to those parents for whom bedsharing should be discouraged (those with hazardous conditions or circumstances), as one must assume that parents may bedshare anyway, even if unintentionally (level 1). See Table 3 for risk minimization strategies.

  • a.

    These discussions can include how to make sleep areas as safe as possible, and can reflect how to minimize hazardous circumstances, even if they are not eliminated (See Table 2 ).

  • b.

    For instance, if a parent who smokes is bedsharing, breastfeeding, sleep positioning, sleep surface, bedding, and where infant naps when alone can all be discussed.

  Table 3

  Risk Minimization Strategies for Families in Which Bedsharing is High Risk

  Increased promotion and support of breastfeeding (level 1) (level 3). Referral for smoking cessation and alcohol and/or drug treatment (level 1) (level 3). Enhanced repeated multimodal messaging regarding risks of sofa-sharing, bedsharing where hazardous factors are present, including sleeping next to an impaired adult and smoke avoidance. Text messaging and e-mail, including use of video and social media may be helpful if available to parents (level 2). Sidecars or in-bed devices (e.g., Pēpi-Pod®; wahakura ) can be considered (level 2). Emphasize room-sharing where and when bedsharing cannot be done safely. Take into account the importance of the partner and other support persons’ involvement in the infants’ sleep time activities.