Why does the American Academy of Pediatrics recommend room-sharing for one year?
I have reached the holy grail of new parenthood: my daughter is sleeping through the night.
pediatrics.aappublications.org/content/105/3/650 Allow me to bask in my reposeful glory:
My daughter has spent the last two weeks sleeping through the night.
In her crib.
In her own room.
While the relative benefits of my 7-month-old sleeping uninterrupted through the night tend to go unquestioned, the fact that she’s doing so in a room all by herself is more controversial.
Technically, it goes against American Academy of Pediatrics (AAP) advice.
In brief, because it falls short of the AAP’s guideline that parents room-share with their babies for at least 6 months, ideally a year. And even though this particular directive is “new” in 2016, it has a much longer history (as usual).
Although it wasn’t necessarily a huge topic of discussion, pediatricians have been advising American parents (read: mothers) where to put their babies to sleep since the field of pediatrics itself emerged in the late 1800s. I discuss this in more detail in the last chapter of my book, Rest Uneasy, but here I’ll just mention some of the most important points:
Starting around 1900, most pediatricians recommended that mothers do everything in their power to teach their babies to sleep alone. Generally speaking, pediatricians advised “the farther the better.” The most essential component of sleeping “alone” involved a baby sleeping separately from his parents, on his own sleeping surface, but if a separate room was available for baby, that was the best option for everyone, physicians said. Doctors were quite adamant about this, and before too long, separate sleeping was so conventional, so customary, that it was the baseline presumption.
As I state in my book, “In the United States and most western cultures, the separation mandate (that children sleep alone on separate sleeping surfaces in separate rooms from their parents) was so culturally engrained in the twentieth century as to be almost taken for granted.” There was nothing perplexing or disconcerting about where or how babies should sleep, and independence was the name of the game.
This seemed to be the case (I argue) for a few reasons, including: 1) cultural norms that chastised parents for coddling babies too much, 2) the prioritization of suburban middle-class homes, and 3) longstanding fears about “overlaying,” described as a parent accidentally rolling over onto a baby and suffocating it.
In the last 20 years, pediatricians’ (re)emphasized the advice that babies and parents should sleep separately, largely in response to the realization that growing numbers of Americans were sharing beds with their babies (bed-sharing). This took the form of the “room-share-but-don’t-bed-share” recommendation.
Last year, a study published in Pediatrics challenged this piece of advice, and parents have since been left wondering and anxious about where their babies should sleep.
Let me explain.
The AAP’s Stance on Room-Sharing
Pediatricians and health care professionals have been weighing in on infant sleep for well over a century, but the first time the AAP formally levied a set of guidelines on infant sleep was in 1992. That year, the AAP told parents to put babies to sleep on their backs to prevent SIDS. At the time, it was a shocking piece of advice, flying in the face of decades worth of pediatric advice and maternal wisdom holding that babies were not only safe to sleep on their stomachs, but also slept better on their stomachs.
This recommendation – backed by a wealth of evidence from the international medical community – spawned the Back to Sleep campaign in the US. And its legacy has been to cut the rate of SIDS in half. Yes: it would be difficult of overstate how momentous these developments in the early 1990s were.
Note that in 1992, the AAP had nothing to say about where a baby should sleep – just that he needed to be on his back.
In 2000, the AAP released an expanded set of guidelines with more details about the ideal sleeping environment and how to position babies. It expressly advised against bed-sharing, and although it neglected to officially make any suggestion about where to put a baby’s crib, the AAP did mention room sharing:
“As an alternative to bed sharing,” the experts said, “parents might consider placing the infant’s crib near their bed to allow for more convenient breastfeeding and parent contact.”
Note: the first mention of room-sharing was merely as a suitable arrangement that families could use instead of bed-sharing.
The next time around, in 2005, the tune was different: the AAP expressly recommended room-sharing – over any other sleeping arrangement – based on “growing evidence” that room sharing was associated with a lower risk for SIDS. “A separate but proximate sleeping environment is recommended,” said the AAP. “The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother….”
So this was a marked change. And it was upheld, and emphasized, in the AAP’s most recent sleep guidelines, issued in 2016: “It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface. The infant’s crib, portable crib, play yard, or bassinet should be placed in the parents’ bedroom, ideally for the first year of life, but at least for the first 6 months.”
What’s perhaps most interesting here, though, is that the AAP chose to accentuate this recommendation without any new evidence. (Indeed, the citations remained exactly as is from the 2005 guidelines… we’ll get to that shortly.)
In support of this piece of advice, the AAP stated that:
So the AAP leveled the room-sharing recommendation based on 2 items: some evidence that room-sharing might be protective against SIDS and the impression that room-sharing is safer for babies than bed-sharing. (We’re going to leave this second piece alone, because it’s a bombshell – another blog post for another day – but needless-to-say, bed-sharing can be very safe. It’s definitely not universally safe, but it is not implicitly dangerous. If you want more on this, let me know.)
For today, I’m interested in the evidence that room-sharing, of its own merit, is the healthiest sleeping arrangement for babies and parents. In a word, it’s…murky.
Where Did the Room-Sharing Recommendation Come From, Anyways?
It appears that the room-sharing recommendation emerged as an alternative to bed-sharing -- it stemmed from opposition to and fears surrounding bed-sharing more than from identification of any distinct advantages it might confer on its own.
The AAP sited the same 4 studies to support the introduction of its room-sharing recommendation in 2005 as it did to re-emphasize and extend that recommendation in 2016. None of them convincingly sustain the claim that room-sharing protects against SIDS.
One (2005) looked at 123 SIDS cases, and the authors’ most important findings had little to do with room-sharing, actually indicating that the correlation was only apparent among families in which parents smoked. Thus, somewhat counterintuitively, room-sharing appeared statistically protective only for babies whose parents were smokers. Another project (2004), also had more to say about bed-sharing than room-sharing, although there was a preponderance of SIDS among babies sleeping in their own rooms. The third citation (1999) comes from an out-of-print book that I (or anyone else, really) can’t get anywhere. But reviewers note that its use of data from the early-mid 1990s basically renders it obsolete (because of the successful implementation of the Back to Sleep campaign during the mid-late 90s). Lastly, the final piece of evidence buttressing the room-sharing guideline is another project from the 1990s, the results of which are similarly outdated, besides also being ambiguous.
We should thus be wary of over-applying these mixed conclusions, and the INSIGHT (Intervention Nurses Start Infants Growing on Healthy Trajectories) project further calls all of this into question. It directly challenges the AAP recommendation to room-share for one year, saying that: 1) the evidence in support of the room-sharing recommendation is insufficient to justify it; 2) the room-sharing guideline doesn’t make sense – both epidemiologically and practically; and that 3) room-sharing might have other unexpected outcomes.
The INSIGHT data are quite compelling. Researchers studied 3 groups of 230 mother-infant pairs: a group of babies who slept in their own rooms by the time they were 4 months (62%), a group of babies who began sleeping in their own rooms between 4 and 9 months (27%), and a group of babies still room-sharing with their parents at 9 months (11%). (Personally, I was shocked at how many babies were sleeping on their own at 4 months and how few babies were still room-sharing at 9 months....)
Researchers found that the earlier babies slept solo, the better they slept: they had fewer night wakings, were more likely to follow a consistent bedtime routine, slept for longer durations, and were less likely to be sleeping in unsafe sleeping environments (namely, be pulled into an adult bed for sleep at some point). The flip side of this, of course, is that 4-9-month-old babies who share a room with their parents – and their parents – sleep "worse."
So given that room-sharing likely contributes to parents’ already-devastating levels of sleep debt, parents can and should fairly ask: why should we room-share for a year?
Well – to be clear, there is some fascinating anthropological research hinting that infant-parent (typically, infant-mother) proximity very well may be protective against SIDS – James McKenna’s research in this arena is particularly cogent. (Although, McKenna’s work played an instrumental role in compelling the AAP to commit to an aggressive stance against bed-sharing in the first place…so it is the ultimate academic irony that his work might now be the AAP’s best line of defense for its take on room-sharing.) For example, McKenna’s research considers that the association between room-sharing and frequent arousals might actually serve an evolutionary benefit. He questions whether the longer, less-punctuated periods of sleep that are ideal for parents are actually safer for babies; perhaps frequent arousals themselves are helpful in defending against SIDS. Besides, room-sharing supports breast-feeding, and may aid in breathing regulation.
Yet the extent to which these possible benefits continue beyond the newborn period is unclear. As Ian Paul, the lead author of the INSIGHT project, explained: “Studies done on SIDS are done across the first year, and they found no difference between room sharing and independent sleeping once the babies got past 120 days, or four months…The sleep location doesn’t really matter beyond that point.”
Indeed, as Paul and his co-authors noted, since 90% of SIDS cases happen in the 0-6-month range (with a majority of those occurring in the 0-4-month range), the length of the AAP’s room-sharing recommendation – a full year – doesn’t make epidemiological sense. Most parents know, too, that one year is right around the time when many babies start to become more aware of their surroundings and experience separation anxiety, both of which could make it much more difficult to initiate separate sleeping at one year versus 4-6 months.
And here’s the other thing – the more we learn about sleep, the clearer it becomes that sufficient sleep is critical for physical and emotional health as well as cognitive functioning. Matthew Walker’s wonderful book Why We Sleep catalogs (in painful detail) the myriad health implications underlying the “silent sleep loss epidemic” in America, but nowhere are parents to be found.
And yet we are everywhere, permanently sleep-deprived. We are driving, working, teaching, cooking, running, writing, listening, paying bills, and parenting. Researchers have yet to evaluate the effects of chronic sleep deprivation among new parents (how could they, really?), but the INSIGHT study adds to this budding, if disconcerting, conversation.
It suggests that parents’ sleep deserves to be factored into pediatric sleep advice and guidelines.
And it reminds us that we should question what the experts have to tell us.
In many ways, the current cultural (and medical) discussions surrounding room-sharing seem to have been instigated by the heated historical and contemporary debates about bed-sharing. In other words, the issue of room-sharing has almost always been discussed as a tangent to the issue of bed-sharing; rarely has it come up on its own merit. And given the scanty evidence sustaining its advantages, perhaps that’s not surprising.
There’s clearly no “right” or “wrong” choice with room-sharing, but given everything that’s at stake – babies’ and parents’ health and well-being – we all need to start having more honest conversations about how we’re going about this whole project of sleeping, and recognizing what we need to sleep well.
One last thing: The initial suggestion that supine sleeping might be a factor in SIDS was met with skepticism, but it turned out to be spot on. The history of SIDS tells us that we need to be willing to question and re-evaluate everything we think we “know” about safe sleep, and we need to be willing to consider that even seemingly-impertinent factors might be important to babies’ safety. The cutting-edge findings in the sleep sciences tell us that we need to stop valorizing sleep deprivation, stop demonizing shared parent-infant sleeping, and start taking sleep seriously. Seriously.
We need to be willing to listen when someone says “let’s consider this.”
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