When Your Baby Is Your Roommate

https://www.nytimes.com/2018/04/02/well/family/baby-sleep-sids-room-sharing.html

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Most parents have heard the advice that babies are supposed to sleep in their parents’ rooms, but for some it’s tough to live up to the recommendations.

Since it became clear in the 1990s that the incidence of sudden infant death syndrome could be reduced by putting babies down on their backs, the rate of SIDS has dropped dramatically, and the “Back to Sleep” campaign, now the “Safe to Sleep” campaign, is regularly — and fairly — cited as highly successful. But several thousand babies still die every year in the United States, around 3,700 in 2015, from all forms of what is called sudden unexpected infant death, of which 1,600 were classified as SIDS, and pediatricians are still trying hard to eliminate those deaths.

In the fall of 2016, the American Academy of Pediatrics revised its guidelines for safe sleep, recommending that infants sleep in the parents’ bedroom — but emphatically not in the parents’ bed — for at least the first six months of the baby’s life, and ideally the first year; the guidelines also recommend a safe sleep surface for the infant, without crib bumpers, stuffed animals, pillows or blankets.

There are families for whom the most important issue is keeping the baby out of the parents’ bed; for them, the idea of room sharing is not likely to seem too close for comfort. But there are certainly other parents who are not sure they can easily manage a year of the baby in a bedside bassinet, and for whom the topic evokes the fraught issues of parental sleep deprivation and “sleep training” for infants. Some parents fear — or find — that having an infant in the bedroom can strain their relationship, making what would otherwise be their private refuge into a place where it’s paramount to be quiet so you don’t wake the baby.

There are now several studies to show that room sharing is associated with a lower risk of SIDS, said Dr. Michael Goodstein, a neonatologist at WellSpan Health, who was a member of the A.A.P. task force on sudden infant death syndrome.

The current model for understanding SIDS suggests a confluence of risks. First, the infant may have some intrinsic anatomic or physiological risk factor. Second, there is a critical period of development when babies are vulnerable, before the age of 6 months. Third, there is an environmental component involving sleep position, bed sharing or overheated rooms. The final mechanism of death may be a failure to arouse out of deep sleep.

Maybe, Dr. Goodstein said, when babies sleep in the same room as their parents, the background sounds or stirrings prevent very deep sleep and that helps keeps the babies safe. Room sharing also makes breast-feeding easier, which is protective against SIDS.

Dr. Ian M. Paul, a professor of pediatrics and public health sciences at Penn State Children’s Hospital, has questioned whether it’s reasonable to suggest that families undertake room sharing for as long as a year.

“It’s clear that room sharing is protective against SIDS in the first four to six months,” when the great majority of SIDS deaths occur, he said. “After that there was no hard data to support that room sharing without bed sharing was any safer than the baby sleeping in their own room.”

Dr. Paul was the first author on an article last summer in the journal Pediatrics that looked at the relationship between room sharing and sleep behaviors. The families that continued room sharing longer, he said, were at higher risk of moving the child into the parents’ bed, which is unsafe. As for babies, “those that moved to their own room sometime after age 4 months had better sleep consolidation and longer overall sleep extended out to age 2½ years.”

Families need to consider all these factors, he said, in figuring out what will work best for themselves and their babies. “We do know that poor sleep has effects on the child in the short and the long term and on the family.”

“I begin at 4 months in my clinical well visit, establishing good bedtime routines, not feeding or rocking a baby to sleep, put a drowsy but not asleep child to bed,” Dr. Paul said. To discuss “transitioning out of the room at 4 months gives me a mental reminder in my anticipatory guidance to reinforce safe sleep in that new sleep environment, and I talk about the potential benefits of having a baby get better sleep consolidation in that second half of the first year.”

In the first four to six months, Dr. Paul said, room sharing can help support breast-feeding. But by 6 months, he says it’s fine for the baby to be in a separate room. The baby should no longer need to be breast-fed overnight, and in fact, mothers may be more likely to keep breast-feeding longer if they are not waking up several times a night.

For women who need to breast-feed in the night, and are concerned that they may fall asleep while nursing, Dr. Goodstein suggested, stay in bed but clear the bed of pillows, loose blankets, comforters — and try to stay awake so that you can put the baby back into a “safe sleep environment,” that is, the bassinet or crib that is not the parental bed. Babies should not be put down on surfaces like water beds, couches or cushioned armchairs, where there is a very large increase in the risk of SIDS.

“Parents need to be aware of norms, that there are going to be awakenings,” Dr. Goodstein said. “At some point when they’re getting a little older, we should give them some time to self-soothe — we need to have these discussions about infant sleep safety, injury prevention, SIDS risk reduction, we need to acknowledge that parents have a hard job.”

Indeed, it is a hard job, and Dr. Paul said that many parents and many pediatricians were relieved by his position.

“I got so much fan mail when we published our paper,” he said. “Pediatricians, many of them, didn’t think it was a common sense recommendation for some families.”

But everyone also understands the desire to see these deaths stop, and no one wants to take risks. “There are still 3,700 babies dying from unsafe sleep in this country, one dying every two or three hours of every day,” Dr. Goodstein said. “It’s a national tragedy. We really have to work at dropping these numbers down.”

Jodi Mindell, a pediatric sleep expert at Children’s Hospital of Philadelphia and chairwoman of the Pediatric Sleep Council, said that while the emphasis in the early months when risk is highest must be on the importance of keeping babies safe, we should also help families think about other aspects of sleep in the period between 3 and 6 months: “Establish good sleep foundations, with early bedtime, consistent bedtime routines.”

She advised that doctors educate parents about safe sleep surfaces and the importance of no one smoking in the home.

“We need to make it safe whether or not the baby is in the parents’ room,” Dr. Mindell said. “Our job is to help families and support them in their decisions.”