Why co-sleeping advice is changing despite the risk of SIDS

When Emily Little gave birth to her first child, co-sleeping in bed with her baby was a given – despite all the public health messages telling her not to.

“I knew it was something I wanted to do,” said Little, a reproductive health researcher and science communication consultant who has studied bed-sharing cultures around the world. Little was attracted to the skin-to-skin closeness she could maintain with her baby through the night, making it easier to breastfeed without getting up. “Since the beginning of human history,” she said, it has felt natural to sleep like mothers and babies.

So she began researching ways to reduce the risk to her baby. Bed sharing in non-smoking, sober homes is less risky for full-term babies who are exclusively breastfed: check. Only the breastfeeding parent should sleep next to the baby: check. Since babies are less likely to suffocate on firm mattresses and without open beds, Little changed her pillow-top mattress and removed all of her blankets and extra pillows. Because children can fall off the bed or fall into the gap between the bed and the wall, put the small bed up against the wall, and fill the gap with foam.

Emily Tate shares her bed with her baby after breastfeeding. Tate is a reproductive health researcher who created a discussion guide for parents and health care providers to address the nuances of bed sharing.

(Tanya Goehring/For The Times)

Still, the toddler’s decision is at odds with the advice of pediatricians and public health advocates, who warn that bed sharing increases the risk of a baby dying during the night. For decades, U.S. pediatric and public health officials have warned that the only way to prevent Sudden Unexplained Infant Death (SUID) is to stick to the “ABCs of safe sleep” — always put the baby to sleep, only on their back, in a separate nursery free of any pillows, blankets, stuffed animals and cribs. One controversial campaign even depicted a baby lying next to a butcher, sending the message that parents can be deadly weapons when sleeping next to their baby.

And it worked: Sleep-related infant mortality rates dropped significantly after the Safe Sleep Campaign began in the 1990s. But in recent decades, the price has risen and even started to rise again, at the same time that bed sharing has become more popular among parents. So some advocates instead turn to a “harm reduction” approach that acknowledges that parents want to sleep with their babies and offers guidelines on how to make them as safe as possible.

“The abstinence-only message hasn’t worked, and parents often aren’t honest with their children’s doctors when they’re asked. We all have to accept that this is practically inevitable,” said Susan Altfeld, a professor emeritus at the University of Illinois at Chicago. “Developing new messages that educate parents about which behaviors are particularly dangerous and what they can do to reduce those risks has the potential to have a transformative effect.”

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Change message about child bed sharing

About 3,700 new babies die suddenly and unexpectedly in the United States each year, a number that has risen sharply in decades, according to data from the U.S. Centers for Disease Control and Prevention. The risk of co-sleeping is real: Babies who sleep with adults are two to 10 times more likely to die than those who sleep alone in a crib, depending on their specific risk factors, the American Academy of Pediatrics, or AAP, wrote in its latest Safe Sleep Guidelines.

However, the percentage of parents in the United States who said they usually bed-share has increased, from about 6% in 1993 to 24% in 2015. And in 2015, 61.4 respondents reported sharing a bed with their children at least sometimes. Although more recent national data is not available, more than a quarter of mothers in California said they “always or often” shared a bed in 2020-22.

Few highlight the positive aspects of bed sharing and help families minimize the risks.

(Tanya Goehring/For The Times)

La Leche League International, a breastfeeding advocacy organization, recommends “Safe Sleep 7” on their website to help parents safely bed-share. Little codified her “harm reduction” advice for safe bed sharing in an online discussion guide for other parents to help encourage meaningful conversations between parents and health care providers to help reduce the risks of what is at least an occasional practice for many parents. She also highlights the positive aspects of bed sharing and helps families minimize the risks.

Babies who bed-share with their mothers, for example, have been shown to breastfeed for longer. Parents who plan ahead and safely bed-share can avoid accidentally sleeping with baby in a very uncomfortable situation – a reclining chair or sofa. And many parents feel it strengthens their bond with their child, she said.

“Babies have a biological expectation to be in close contact with their caregivers at all times, especially in the early months,” Little said. “To deny it because we as a society can’t talk about risk reduction and harm reduction is actually damaging to children’s well-being and mental health.”

Pushback from safe sleep advocates

The Academy of Pediatrics, in its 2022 guidelines, acknowledges that parents may “choose to regularly bed-share for a variety of reasons,” and offers some safety suggestions if a parent “involuntarily” co-sleeps with their child. “However, based on the evidence, the AAP cannot recommend bed sharing under any circumstances,” the guidelines state.

It’s almost impossible to assess whether a family is truly a low-risk group when it comes to bed sharing, especially since many people don’t know about drinking, smoking and drug use with their doctor, said Dr. Rachel Moon, a pediatrician and researcher at the University of Virginia School of Medicine, and lead author of the AAP report. Even if a parent is at low risk, when they have a glass of wine one evening, they suddenly jump into the high-risk category, she said.

“I knew this was what I wanted to do,” The younger one, shown with her family, said of sharing a bed with her child.

(Tanya Goehring/For The Times)

Moon said the advisability of bed sharing had been a topic of discussion in academia for years, but given the evidence of risk, the group decided to warn against the practice in all circumstances.

“It is not our responsibility to make transactions [parents] Permit, said Moon, who deals with death as a researcher in sleep. “Every day I deal with children who die, and if it happens in a bed-sharing situation, [parents] Alas, I deal with it so much that I don’t want anyone to regret it.

Changing the messaging about safe sleep will be a “sticky piece,” said Dean Tilton Durfee, executive director of the Interagency Council on Child Abuse and Neglect, which runs the L.A. County Safe Sleep Campaign. “You have to be very clear with the messaging” because many parents may not pay attention to the details, she said.

In 2024, 46 new babies died in their sleep in Los Angeles County, and almost all of them were involved in bed sharing, Durfee said.

Reality in parents’ homes

Pachet Bryant, a mother in Mission Viejo, felt a deep commitment to sleep with her newborn from the moment of birth. “You’re growing a baby for nine to 10 months, and suddenly for them to be separated from your heart, from your presence, from your scent, can be traumatic,” she said.

But she wanted to do it as safely as possible. So when lactation consultant Isaiah Harwell started working with her, the consultant offered advice tailored to the new mom’s situation, which Bryant took “very seriously.” Bryant had already done some research of his own and was able to reposition her accordingly. She also reassessed each night whether she felt it was safe for her child to sleep in the bed; At night when she was very tired, she put her daughter to sleep in a bag instead of her.

“We know that parents either intentionally or unintentionally sleep with their baby at some point, and we need to think about creating the safest possible environment for that,” Harwell said. In the lived reality of a single-family home, she said, “we can’t just teach altruism.”

This article is part of The Times’ Early Childhood Education Initiative, which focuses on the learning and development of California children, birth to age 5. To learn more about the initiative and its charitable donors, go to latimes.com/earlyed.