Loss of an infant is one of the most difficult experiences families can live through. As health care professionals, not being able to provide a clear reason for the death is also a significant burden. The American Academy of Pediatrics (AAP) 2016 updated document on safe sleep indicates that “approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome, ill-defined deaths and accidental suffocation and strangulation in bed” (Moon). Sudden unexpected infant death (SUID) describes death occurring during infancy that may or may not be explainable. This can include suffocation, entrapment, infections, disease, trauma and sudden infant death syndrome (SIDS).

There was a significant decrease in death rates attributed to SIDS with the back to sleep campaign which started in 1994. Since 1998 there has been a move away from using the SIDS terminology with coroners and medical examiners to the more inclusive SUID description. Investigative practices and determining cause of death have been inconsistent in years past, which lead to difficulty in monitoring and determining risk factors. This eventually led to the development of training programs for investigators and others who investigate infant death.

Statically there is a higher incidence of infant sleep-related deaths among American Indians/Alaska Natives, followed by non-Hispanic black families. New Zealand, which is the country with the highest incidence of SUID in the world, also has a disproportionately higher rate amongst indigenous populations. Increased rates of smoking during pregnancy, higher rates of non-exclusive breastfeeding or no breastfeeding, and non-supine sleep positions have been recognised as possible reasons for the disproportionately higher rate when compared with other populations. The Netherlands and Japan have among the lowest rates of infant sleep-related deaths in the world.

As more knowledge has been gained, there has been a realization that there are both modifiable, and non-modifiable risk factors associated with sleep-related infant deaths. The most well-known publicised modifiable risk factor is changing infant prone or lateral sleep position to a supine sleep position, the back to sleep campaign. Lesser publicised and known modifiable risk factors are related to smoking during pregnancy, which is a significant risk factor, and infant feeding. Education about smoking during pregnancy and sleep-related death needs to be included in all stop smoking education programs including in high school. There have been local and state programs to address this. For example, records show that “white mothers and mothers aged <19 years have had the highest prevalence of smoking during pregnancy…To help reduce smoking among pregnant women, West Virginia launched the "Tobacco Free Pregnancy Initiative" in 2009, with resulting increases in calls to tobacco quitlines by pregnant women and their families” (Centers for Disease Control and Prevention, 2013).

Not breastfeeding also increases the risk factor. Yet in most documents breastfeeding is simply mentioned in the list of good things to do. Breastfeeding is almost always mentioned along with the reminder to not bedshare or co-sleep. The 2016 AAP update on sleep related deaths acknowledges having ever breastfed was associated with a decreased risk of SIDS. Exclusive breastfeeding is recommended. The document also acknowledges that parents sometimes bring infants into bed to cuddle and feed and sometime parents may fall asleep with these infants. The recommendation to return the infant to its own sleep environment is strongly recommended when parent wakes and realizes infant is in bed with them. This is leaving parents with mixed messages.

Probably one of the most publicised and possibly controversial sleep-related death prevention strategy in recent years has been the strong recommendation of no bedsharing or co-sleeping. Yet non-smoking families and mothers, who make an informed decision to breastfeed as a modifiable protective practice, are likely to find themselves with their babies in an unsafe environment trying to follow this recommendation. Families who chose to co-sleep with their infants, may not share that they are doing so with their health care professional. They may be concerned they will be judged for their actions. They also may not know about other risk factors that are unsafe. If there is no conversation, no safe practice information can be shared. There may also be a mistrust of health care professionals. Families may not relate to the health care professional, as he or she may not be from their community, and therefore they cannot relate to the practices being recommended.

Anthropologists James McKenna and Helen Ball have been researching mother-infant sleep environments for decades. As anthropologists they view mother-infant sleep from an evolutionary sociohistorical perspective. Which differs to the pragmatic Euro-American historical nighttime sleep separation assumptions, and at times non-evidence based medical advice (Bartick, Tomori, & Ball, 2017).  As health care professionals it is important to review the research with eyes wide open. This includes reviewing perhaps why the “‘Never Bed-share’ message may not only hinder maternal and child health promotion by impeding breastfeeding, but also SIDS reduction itself, as formula-use is associated with increased SIDS” (Ball, 2017).

Breastfeeding is behaviourally and physiologically intertwined and functionally symbiotic with co-sleeping. The word breastsleeping was coined with the aim to help “resolve the bedsharing debate and to distinguish the significant differences (and associated advantages) of the breastfeeding–bedsharing dyad when compared with the nonbreastfeeding bedsharing situations, when the combination of breastfeeding–bedsharing is practiced in the absence of all known hazardous factors” (McKenna & Gettler, 2015).

When we as health care professionals discuss breastfeeding and co-sleeping recommendations we have a responsibility to share evidence-based knowledge. Please when speaking to colleagues and families remember these words “co-sleeping for the breastfeeding mother is “normative” human behavior; it is not “surprising," unexpected, nor irresponsible nor child abuse nor neglect; it is not immoral nor inherently stupid nor ignorant parental behavior” (McKenna, n.d.).  


Ball, H. L. (2017). The Atlantic divide: Contrasting U.K. and U.S. recommendations on cosleeping and bed-sharing. Journal of Human Lactation33(4), 765-769. doi:10.1177/0890334417713943

Bartick, M., Tomori, C., & Ball, H. L. (2017). Babies in boxes and the missing links on safe sleep: Human evolution and cultural revolution. Maternal & Child Nutrition, e12544. doi:10.1111/mcn.12544

Centers for Disease Control and Prevention. (2013, August 9). CDC grand rounds: Public health approaches to reducing U.S. infant mortality. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6231a3.htm?s_cid=mm6231a3_e

McKenna, J. (n.d.). What every health professional should know // Mother-baby behavioral sleep laboratory // University of Notre Dame. Retrieved from http://cosleeping.nd.edu/what-every-health-professional-should-know/

McKenna, J. J., & Gettler, L. T. (2015). There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatrica105(1), 17-21. doi:10.1111/apa.13161

Moon, R. Y. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics138(5), e20162938. doi:10.1542/peds.2016-2938

Statistics. (n.d.). Retrieved from https://www.ncemch.org/suid-sids/statistics/#disparities