Counting sheep: Breastfeeding Infants
and Sleep Safety
Elizabeth A Fleming, MD
Dean Clinic East
Family Medicine
Disclosures and Gratitude:
 I have no relevant personal financial relationships or
any commercial interests.
 The content of this presentation was prepared by me
and does not reflect the views and opinions of Dean,
St. Mary’s Hospital or SSM.
 Thank you to Ildi Martonffy and Laura Berger for your
guidance in preparing for this talk, to Daniel
Stattelman-Scanlan who generously allowed me to
share Dane Co Public Health data, and to those of you
who took the time to fill out the survey.
Objectives
 Define Sudden Infant Death syndrome and Sudden
Unexplained Infant Death and review current
recommendations.
 Discuss benefits of breastfeeding as they relate to risk
of SUID/SIDS.
 Review existing evidence around co-sleeping, roomsharing, and bed-sharing.
 Discuss current symposium attendee practices
regarding infant sleep and counseling.
People are talking about this…
Sudden unexplained infant death
 the death of a previously healthy infant, less than 365
old, that occurs suddenly and unexpectedly, and the
cause of death is not immediately obvious prior to
investigation.
 SUID can be attributed to:
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Suffocation
Asphyxia
Entrapment
Infection
Ingestions
Metabolic disease
Arrhythmia
Trauma (accidental or non-accidental)
Defining SIDS
 AAP Policy Statement 2011:
 “Sudden infant death syndrome (SIDS) is a cause
assigned to infant deaths that cannot be explained after a
thorough case investigation, including a scene
investigation, autopsy, and review of the clinical history.”
 This is different than sudden unexplained infant death
(SUID).
Co-sleeping
 When an infant sleeps in close proximity with one or
both parents.
 Room sharing: when an infant sleeps in the same
bedroom as one or both parents
 Bed sharing: when an infant sleeps in the same bed as
one or both parents
SUID statistics
 According to the CDC, about 3,500 infants die
suddenly of no immediately, obvious cause in the US
every year.
 In 2013, about 1,500 deaths reported as SIDS
 21 cases of SUID in Dane County from 2011 - 2014
Current AAP Guidelines
Breastfeeding is recommended
 2011 Meta-analysis of 18 case-control studies
(n=2,810)
 Breastfeeding was protective against SIDS for all
groups
 Any amount of breast milk for any duration
(multivariable SOR 0.55 95% CI 0.44-0.69)
 Exclusive breastfeeding for any duration showed a
greater reduction (univariable OR 0.27, 95% CI: 0.240.31)
Sleep position
 The Supine Sleep Position Is Recommended for Infants
to Reduce the Risk of SIDS; Side Sleeping Is Not Safe
and Is Not Advised
 Once an Infant Can Roll From the Supine to Prone and
From the Prone to Supine Position, the Infant Can Be
Allowed to Remain in the Sleep Position That He or
She Assumes
Bedding
 Pillows, Quilts, Comforters, Sheepskins, and Other Soft
Surfaces Are Hazardous When Placed Under the Infant
or Loose in the Sleep Environment
 Wedges and Positioning Devices Are not
Recommended
 Bumper Pads and Similar Products Are not
Recommended
Prenatal and Postnatal Exposures
 Pregnant Women Should Seek and Obtain Regular
Prenatal Care
 Smoking During Pregnancy, in the Pregnant Woman's
Environment, and in the Infant's Environment Should
Be Avoided
 Avoid Alcohol and Illicit Drug Use During Pregnancy
and After the Infant's Birth
Other Recommendations
 Consider Offering a Pacifier at Nap Time And Bedtime
 Avoid Overheating and Head Covering in Infants
 Infants Should Be Immunized in Accordance With
Recommendations of the AAP and Centers for Disease
Control and Prevention
 Although Swaddling May Be Used as a Strategy to
Calm the Infant and Encourage Use of Supine Position,
There Is Not Enough Evidence to Recommend It as a
Strategy for Reducing the Risk of SIDS
Sleep Surfaces
 Infants Should Sleep in a Safety-Approved Crib,
Portable Crib, Play Yard, or Bassinet
 Car Seats and Other Sitting Devices Are not
Recommended for Routine Sleep at Home or in the
Hospital, Particularly for Young Infants
Co-sleeping
 Room-Sharing Without Bed-Sharing Is Recommended
 There Is Insufficient Evidence to Recommend Any BedSharing Situation in the Hospital or at Home as Safe;
Devices Promoted to Make Bed-Sharing “Safe” Are Not
Recommended (ie cosleepers or sidecars)
 There Are Specific Circumstances in Which Bed-Sharing Is
Particularly Hazardous
 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
ABM Recommendations
 Any recommendations for infant care that impede
breastfeeding need to be carefully weighed against
benefits.
 Do not assumed that all families are practicing one
sleeping arrangement only.
 Parents need to be encouraged to express their views
and seek information.
 “There is not currently enough evidence to support
routine recommendations against co-sleeping. Parents
should be educated about risks and benefits of cosleeping and unsafe co-sleeping practices and should
be allowed to make their own decisions.”
ABM Recommendations
 Some potentially unsafe practices to bed sharing:
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Environmental smoke exposure/maternal smoking
Sharing sofas, couches, or daybeds
Sharing water beds or use of soft bedding
Sharing beds with adjacent spaces that could entrap an
infant
Prone or supine position
Alcohol or mind altering drugs
Bed sharing with other children
Bed sharing with younger babies <8-14 weeks of age
may be more strongly associated with SIDS
ABM Safe Sleep Recommendations
 Place babies in the supine position.
 Room sharing appears to be protective against SIDS.
 Use a firm, flat surface. Avoid waterbeds, couches,
sofas, pillows, soft materials, loose bedding.
 If blankets, they should be tucked around the mattress
so the infant’s head is less likely to be covered.
 Ensure that the head will not be covered.
 In a cold room the infant could be kept in an infant
sleeper to maintain warmth.
 Avoid the use of quilts, duvets, comforters, pillows and
stuffed animals.
ABM Safe Sleep Recommendations
 Never put an infant down to sleep on a pillow or
adjacent to a pillow.
 Never leave an infant alone on an adult bed.
 Inform families that adult beds have potential risks and
are not designed to meet federal safety standards for
infants.
 Ensure there are no spaces between the mattress
which may entrap the infant.
 Placement of a firm mattress directly on the floor away
from walls may be a safe alternative. Another
alternative I the use of an infant bed that attaches to
the side of the adult bed. (No studies about this)
In my professional opinion, bed sharing
increases the risk of SIDS.
Sorted by: If you have
children, did your infant
sleep in the same bed as
you and your partner (ie.
Bed sharing)?
In my practice, I counsel parents:
Sorted by: If you have
children, did your infant
sleep in the same bed as
you and your partner (ie.
Bed sharing)?
Substance Use: Multicenter European Study
 17 European countries and 20 centers included, data
from 1992 to 1996
 Case control study published in 2004
 745 cases of SIDS and 2411 controls
 Multivariate analysis revealed increased risk of SUID if:
 Mother smoked and bed shared (OR 17.7, 95% CI 10.330.3)
 Maternal smoking, others in household smoking
independent of bed sharing (>10 cigarettes per day)
 Maternal consumed 3+ drinks vs none in the last 24
hours (OR 2.36, 95% CI 1.18-4.71)
Other Risk factors:
Multicenter European Study
 History of ALTE (OR 2.76, 95% 1.76-4.32)
 Prone position (OR 13.1, 95% CI 8.51-20.2)
 Male gender (OR 1.49 (95% CI 1.11-1.99)
 Birth weight <3500 g
 Maternal age <30
 Previous livebirths
 Marital status
 Employment status (OR 1.85, 95% CI 1.39-2.45)
 Decreased risk with room sharing usually (OR 0.48, 95% CI
0.34-0.69) and at last sleep (OR 0.32, 95% CI 0.19-0.55)
Bed Sharing: Multicenter European Study
 The increased risk of SIDS if the mother did not smoke but
shared a bed was not statistically significant (OR 1.56 95%
CI 0.91-2.68)
 But there was a statistically significant increased risk if the
infant was less than 8 weeks old.
Chicago Infant Mortality Study
 Population-based case-controlled study
 260 SIDS cases from Chicago, November 1993 - April 1996
 Population: 75.0% black, 13.1 hispanic-white, 11.9% nonhispanic white
 Multivariate analysis revealed independent risk factors for
SIDS
 prone sleeping position (aOR 2.3; 95% CI, 1.3-4.3)
 maternal smoking during pregnancy (OR 4.3; 95% CI, 2.1–8.9)
 soft sleep surfaces (OR 5.2; 95% CI, 2.6-10.2)
 pillow use (OR 2.8; 95% CI, 1.3-6.2).
 not using a pacifier (OR 2.9, 95% CI, 1.4-6.0)
 bed sharing in combinations other than the parents alone (OR
3.6; 95% CI, 1.4–9.4)
 bed sharing by infants with mothers or mother and father did
not significantly increase SIDS risk (OR 1.4; 95% CI, 0.7–2.8)
 Breastfeeding was found to be protective (Adjusted
univariate analysis, OR 0.4, CI 0.2-0.7)
The German Sudden Infant Death Syndrome Study
 Population-based case control study from 1998-2001
 333 SIDS cases and 998 matched controls
 Detailed questionnaire filled out with parent, autopsy using
standard protocol, multidisciplinary panel to determine SIDS vs
SUID.
 Demonstrated increased risk via multivariate analysis if:
 Bed sharing (OR 2.73, 95% CI 1.34-5.55)
 Sleeping at a friend’s or relative’s (OR 4.39, 95% CI 1.11-17.38)
 Sleeping in the living room (OR 2.41, 95% CI 1.06-5.51)
 Prone sleeping position (OR 7.08, 95% CI 8.93-50.73)
 Duvets (OR 2.20, 95% CI 1.21-4.00 thick, OR 1.92, 95% CI 1.07-3.45
light)
 Decreased risk if:
 Pacifier use (OR 0.39, OR 0.25-0.59)
Scotland Case Control Study
 123 infants who died of SIDS and 263 controls between
1996 to 2000
 Sharing a sleep surface was associated with SIDS
(multivariate OR 2.89, 95% CI 1.40, 5.97).
 The largest risk was associated with couch sharing (OR
66.9, 95% CI 2.8, 1597).
 Of 46 SIDS infants who bedshared during their last sleep, 40
(87%) were found in the parents' bed.
 Sharing a bed when <11 weeks (OR 10.20, 95% CI 2.99,
34.8) was associated with a greater risk, P=.010, compared
with sharing when older (OR 1.07, 95% CI 0.32, 3.56).
 The association remained if:
 Mother did not smoke (OR 8.01, 95% CI 1.20, 53.3)
 The infant was breastfed (OR 13.10, 95% CI 1.29, 133).
Individual level analysis of five
case-control studies:
 Individual data from five major case-control studies
were combined to estimate the risk associated with bed
sharing.
 1472 cases, 4679 controls of a similar age.
 Bed sharing - defined as when one or both parents
slept with the baby in their bed so that they woke to find
the baby dead in bed with them.
 Breastfed – infant was being partially or completely
breastfed at the time of death or interview.
 Peak incidence rate between 7 and 10 weeks.
Individual level analysis of five
case-control studies:
 For room sharing, breast-fed babies placed supine
whose parents do not smoke and have no other risk
factors the SIDS rate is predicted to be 0.08 (0.05 to
0.14)/1000 live births.
 For bed sharing, breast-fed babies placed supine
whose parents do not smoke and have no other risk
factors, the SIDS rate is predicted to be 0.23 (0.11 to
0.49)/1000 live births.
 This is a 2.7 fold increase in risk (CI 1.4 to 5.3
p=0.0027). There is a 5.1 fold increase in risk for
the first 3 months of life (CI 2.3 to 11.4 p=0.00006).
Adjusted ORs (AORs; log scale) for Sudden Infant Death Syndrome by age for bed sharing
breast-fed infants, when neither parent smokes and both smoke versus comparable infants
sleeping supine in the parents’ room.
Robert Carpenter et al. BMJ Open 2013;3:e002299
©2013 by British Medical Journal Publishing Group
Bedsharing Promotes Breastfeeding
 35 Latina mother-infant pairs, 20 routinely bed sharing, 15 solitary
sleeping
 Observed for 3 consecutive nights in a sleep center
 For the routinely bed-sharing group on the bed-sharing night vs
the routinely solitary sleeping on the solitary night:
 There were twice as many episodes of breastfeeding (p<.001)
 Total duration of episodes was nearly three times greater (P<.001)
 Mean duration of episodes was 39% greater (p=.039)
 For the routinely bed-sharing group, the number (p=.006) and total
duration of breastfeeding episodes (p<.001) were significantly
greater on the bed-sharing night than the solitary night with no
significant difference in the time in bed or total sleep time
Bedsharing Promotes Breastfeeding
 Replicated by Gettler and McKenna with 52 motherinfant pairs
 Mother-infant pairs engaged in a greater number of
feeds while bed sharing than room sharing (p<.001)
 There was a lower interval between feeds (<0.05)
Breastfeeding, Bed-Sharing and Infant
Sleep
 253 families completed the study, July 1998-February 2000
 1-month and 3-month sleep logs and interview
 Breastfed and formula-fed infants exhibited different sleepwake patterns
 Formula-fed, but not breastfed infants had a significant
reduction in frequency of night feeds between the first and
third months
 65% of infants who had “ever breastfed” slept in their
parent’s bed (at least occasionally) as compared with 33%
of formula-fed infants (p<0.000001)
Breastfeeding, Bed-Sharing and
Infant Sleep
 There was an association between bed-sharing at 1
month and breastfeeding to at least 16 weeks (p=0.02)
 Among mothers who were unemployed or had
unskilled occupations, there was a significantly longer
duration of breastfeeding among bed-sharing mothers
as compared with those who were not (p=0.032)
SUID Case Registry Pilot Program
 Collaboration between the CDC and the National Center for
the Review and Prevention of Child Deaths (NCRPCD)
 Funded by the Health Resources and Services
Administration
 Objectives:
 Collect accurate and consistent population-based data about
the circumstances and events associated with SUID cases
 To improve the completeness and quality of SUID case
investigations
 Use a decision making algorithm with standard definitions to
categorize SUID cases.
 States: AZ, CO, LA, MI, MN, NJ, NM, NH, WI
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