AAP No Bed-Sharing Recommendation At Odds with Breastfeeding Unintended Risks of American Academy of Pediatrics (AAP) Sleep Recommendations

The AAPs updated recommendations for safe infant sleep better emphasize the importance of infant proximity to a parent at night, both for safety and for breastfeeding success. This represents progress towards better outcomes for babies.

Attachment Parenting International, API, which has advocated for ensuring safe child sleep, both physically and emotionally, for more than 22 years states:

The AAP advises parents to have infants in the same room at night, citing evidence that SIDS risk can be reduced by 50% when parents and infants sleep near each other. This advice … will help parents avoid controversial practices of sleep training, “cry it out” methods, or solitary infant sleep. (1)

The Unintended Risks of American Academy of Pediatrics (AAP) Sleep Recommendations

The updated AAP report still hands down unconditional advice against bed-sharing even though there is inconclusive evidence linking it alone to risk of infant death. All of the studies used to evaluate the risks associated with bedsharing cited in the AAPs technical report suffer from serious methodological flaws, according to ENI independent sources, like Tracy Cassels, PhD, at Evolutionary Parenting. For example, almost all the studies discussed in the AAPs companion paper either fail to tease out other known risk factors (e.g.: smoking, use of soft bedding, etc.) or, after considering separate, additional risk factors, they do not find an increased risk when bedsharing with an infant over 4 months. In examining the report, Cassels explains,

The research on bed-sharing itself [without modifiable risk factors] is inconclusive, so at this point, it should be entirely left up to families with zero demonization. In fact, even when we consider some of the big risk factors (with the exception of smoking) [associated with bed-sharing], they don’t pan out as issues in older infants, which means anything going against bedsharing is ignoring that at the least it’s as safe as being in a cot [crib] in the same room.

Yet the AAP assumes the dangers of bedsharing, when the AAP report states: “Infants who are brought into the bed for feeding or comforting should be returned to their own crib or bassinet when the parent is ready to return to sleep.”

Researchers in the field of infant sleep point out the dangers of the AAP position. For example, Peter S. Blair, PhD, and colleagues reveal one way the one-size-fits-all advice against bed-sharing proves problematic: “In our study in 2003–6, a number of families whose infants died informed us that they had been advised not to bed-share and thus fed the infant (and fell asleep [accidentally]) on a sofa.” (Sofa sleeping is a well-established risk factor.)

Others, like infant sleep researcher Dr. James McKenna, have warned against sweeping public health condemnations against any and all bedsharing. They argue that parents who elect to bed-share should be provided comfortable medical and public health venues to discuss their choices and be given safe bedsharing guidelines. In response to these concerns, the AAP report states:

The AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep.

It’s a Catch-22 for parents. The AAP tells parents that it’s dangerous to fall asleep feeding their babies out of their bed and yet warns against bed-sharing. This is why blanket anti-bedsharing recommendations raise concerns for researchers like Cassels: “This [recommendation] is not feasible, and in my opinion, downright negligent to tell parents.” Cassels explains:

What the AAPs advice likely means in practical terms is the mother not sleeping very much for the first four months as babies feed a lot during this time. This can mean going off breastfeeding early, or ending up in very dangerous bedsharing situations where Mom is overtired and now bringing baby to a bed that is not set up for safe bedsharing.

The problem with the logic behind “just avoid bedsharing to be on the safe side”—the position from which the AAP currently operates—is that bed-sharing promotes breastfeeding and breastfeeding reduces the risk of infant death up to 80 percent.

Advising all parents against bed-sharing under all circumstances puts babies at an increased risk for breastfeeding failure and early weaning, each of which carry clear and significant risks for short term and long term health, including infant death.

With blanket advice, parents will try to avoid both falling asleep while feeding and bed-sharing. Since breastfeeding tends to induce sleep in the mother and bed-sharing is more conducive to breastfeeding, in an attempt to follow the AAP recommendations more parents are likely to switch to formula feeding. But this increases the risk of infant death 2.1 fold by itself.

Despite overwhelming research demonstrating the risks of formula feeding, the AAP stopped short of asserting breastfeeding as mitigating the risk of bedsharing (if such risk exists in itself). This decision was based on a single study by JH Ruys and colleagues published in Acta Paediatrica. The Ruys study states that bedsharing is a risk factor for SIDS regardless of breastfeeding status, but there are once again other risk factors lumped in with bed-sharing that make their conclusion problematic according to Cassels, who has analyzed the studies on this topic in depth. Specifically, the study doesn’t control for smoking or the use of soft bedding, both of which were far higher in the bed-sharing group. Cassels explains:

In this study, 72% of SIDS-bedsharing families used a quilt compared to 16% of controls. In other research tog value (the unit of measure for thermal resistance) has been found to be a huge risk factor for SIDS and duvets and the like have higher tog values. Unfortunately, if this was included in the analyses, it was not reported on. Yet, given the data at hand, I can say the univariate odds-ratio is 13.68, greater than the highest risk of bedsharing. Furthermore, 64% were using a pillow for baby in the SIDS-bedsharing group compared to 2% of controls, resulting in an odds-ratio of 88.24, a ridiculously high number based on the very low percentage of pillow-use in the control group. After all, these variables were intricately linked with bedsharing yet are not inherent to bedsharing and thus can be modified if safe bedsharing is taught.

The AAP’s conclusion is contrary to Dr. James McKenna’s notion of “breastsleeping,” which posits that bedsharing and breastfeeding go hand-in-hand from a biological or anthropological perspective. McKenna’s work emphasizes how very different breastfeeding mothers are in terms of awareness of their babies during bed-sharing. McKenna states:

Breastsleeping by mother–infant pairs comprises such vastly different behavioural and physiological characteristics compared with nonbreastfeeding mothers and infants, this dyadic context must be distinguished and given its own epidemiological category and benefits to risk assessment.

When babies will not sleep outside the parents’ bed without crying, parents are logically led toward “cry-it-out” sleep training, which isolates infants, increasing the risk for infant death by 50 percent, a statistic the AAP report also includes.

What does all this mean in terms of advising parents? Health care professionals should avoid blanket statements about bed sharing. Instead, recommendations should be individualized for families. API director, Samantha Gray would like to see doctors individualizing recommendations that avoid putting parents in an impossible situation. She contends: “Parents need information on bedsharing and then they need to be empowered to make decisions about their children like they will on a million different issues in their lives.”

Further analysis of the Ruys study by Dr. Cassels.

The Evolved Nurturing Initiative’s Position:

ENI believes the AAP has made great strides in acknowledging the importance of breastfeeding and avoiding infant isolation. However, the practical implications of catch all advice against bed-sharing are problematic for breastfeeding mother-infant pairs, and may inadvertently increase formula feeding and therefore other risks like poorer health and even infant death.

The Evolved Nurturing Initiative™ is a nonprofit, educational initiative guided by a science council to provide grounded insights into current research without cultural bias or special interest influence.

[1] The nonprofit free parent information and support group, Attachment Parenting International (API), which has advocated for ensuring child safe sleep, both physically and emotionally, for more than 22 years, continues to advocate that still more can and should be done to provide accurate information and support to parents.


This press release is from the Evolved Nurturing Initiative.

The Evolved Nurturing Initiative ™ (ENI) generates best-practice advice for child-raising using a scientific think tank. ENI’s mission is to filter out cultural, industrial, and political influences that distort scientific research and provide unbiased reporting on child raising that meets the critical, innate developmental needs of babies and young children. ENI is geared to help parents and policy makers understand and overcome the censorship and misinterpretation surrounding what children need. ENI promotes the re-evolutionary discovery of evolved child-raising practices supported by interdisciplinary research. We are not pro or anti any specific aspect of child care, rather, we are pro- untaited science.

When we analyze the pure science, the explosion of research supporting the special developmental protections supplied by intimate and responsive physiological care practices come to light. We aim to make this evidence more accessible to media and parents.

We also report with and eye toward a paradigm that better aligns with our goals as a society. Converging evidence from across scientific disciplines confirms what our ancestors knew intuitively and passed on from experience: Particular care-giving strategies evolved to optimize social, emotional, and intellectual development. These result in healthier and more cooperative and compassionate children, then adults, and ultimately, society. We comb the research to illuminate what cultivates humanity’s potential, and therefore translates to the innovation and success we want for children. Focusing on what society agrees on, ENI spotlights the most effective way these goals are seeded in early parenting.

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