Mother-Infant Room-Sharing and Sleep Outcomes in the INSIGHT Study

In this article authors try to assess the association between room-sharing and sleep outcomes of parent and baby. This paper is part of INSIGHT project, a longitudinal, randomized, controlled trial evaluating a responsive parenting intervention designed for the primary prevention of obesity. Considering that in our industrialized societies childhood obesity rates have reached epidemic proportions, is evident that the objectives of the INSIGHT study are of great importance for public health. But, after reading carefully this publication I can only show my surprise and disappointment at the ethical and scientific approval of this project, and the reasons for that are the following:
1. The Sleeping Measurements are Based on the Parents Answers, and although authors admit this limitation, intentionally deny its real importance. There is plenty of evidence that parents who do not sleep with their babies, unlike parents who roomshare, do not report all awakenings or sleep disturbances, and this completely invalidates questionnaires as an acceptable methodology for the studies whose objective is to make official recommendations on infant sleep location. These studies must be focus on what is really happening to infant sleep, not on what parents perceive that is happening.
2. The Responsive Parenting rules that authors give to the parents concerning infant sleep are not responsive at all, because they are not in accordance with infant’s needs, at least not for infants under 6 months, and definitively not for breastfed infants. On the contrary, they are based on a cultural construction, and they ignore completely the natural and healthy nocturnal behavior of breastfed babies.
3. In addition, there is also an enormous cultural bias on the design and interpretation of the study, which prevail over the scientific evidences, in two fundamental areas of infant and children health: infant sleep and breastfeeding. This bias is clearly reflected on the naturalization of solo-sleeping. It is clear from the beginning that not only the authors have big prejudices against cosleeping, but also that they accept as true that the longer and more consolidated night sleep of solo-sleeping babies is healthier than the more fragmented and shorter night sleep of cosleepers, without any real scientific evidence to support it. In fact, scientific evidence has shown us that it is clearly not healthier for breastfed babies.
4. Breastfeeding is not just any feeding, and authors do not take into account differences between breast, formula and complementary feeding when providing advice on solo sleeping, nor when recommending not to feed the baby before or during the night (sleep) after 4 months of age. Breast fed babies (especially exclusive breastfed babies) need to be fed at night, and to forbid it is a big obstacle for breastfeeding. When breastfeeding finds too many obstacles on its way, babies do not gain weight good enough. Usually it forces healthcare professionals to advice mothers to introduce supplementary food too early, or to give to the baby a supplement of formula milk. In this conditions mothers tend to wean too early, what, among other negative effects on baby and mother’s health, also increases the risk of obesity.

Breastfeeding is the gold standard of infant feeding during the first year of life, complemented by solids in the second half year. The promotion of breastfeeding might be an effective measure to prevent obesity (World Health Organization 2014), which was the primary aim of the INSIGHT study. As is well known, breastfeeding reduces mortality and morbidity among infants and mothers. However, insufficient milk supply remains the most frequent reason for the abandonment of breastfeeding (Walker 2016). The most common contributor to insufficient milk supply is mismanagement of breastfeeding, inter alia, a limited number of feedings and scheduled feedings that do not coincide with the infant´s feeding-readiness (Walker 2017). Abandonment of night feedings was found to be associated with weight faltering, return to night feedings (after breastfeeding counselling) led to catch-up growth (Guóth-Gumberger 2011). Also Paul et al. observed that babies sleeping solo breastfeed less at night: They consider it as something positive (with regard to obesity prevention) and do not recognize the danger of weight faltering and premature termination of breastfeeding.
On average, eight to twelve feedings in 24 h are required to sustain exclusive breastfeeding during the first six months (Guóth-Gumberger 2011). In particular, mothers with low breast storage capacity need to breastfeed frequently and, in order to maintain their milk supply, must not skip night feedings (Guóth-Gumberger 2011).
In line with these findings, co-sleeping has been shown to have a strong positive and bidirectional relation to breastfeeding duration (McKenna & Gettler 2016): Breastfeeding mothers co-sleep more than bottle-feeding mothers and mothers who co-sleep breastfeed more frequently and longer than mothers who do not. Even just room-sharing is significantly related to more breastfeeding. Solo-sleeping and too early consolidated night sleep are obstacles to successful breastfeeding.
In our society, we are far away from achieving WHO and AAP recommendations on optimal breastfeeding. This is the reason why it is so important to promote parenting habits that facilitate the initiation and maintenance of breastfeeding. Interventions of the INSIGHT study, which do not distinguish between breastfeeding and formula feeding, might undermine breastfeeding success and thus increase the risk of what they claim to prevent: obesity. These harmful interventions of the INSIGHT study include the promotion of solo sleeping, avoidance of breastfeeding for comfort and for sleep, with 8–12 h (!) without feeding at night beyond the age of four months. Such long gaps without breastfeeding would reduce milk production.
Also, it is most questionable if it is ethical to withhold breastfeeding for comforting a baby, as suggested by the INSIGHT authors for obesity prevention. In many cases, breastfeeding is the most effective method to calm a fussy baby. Accordingly, breastfeeding is an effective non-pharmacological strategy for pain relief, too, more effective than other interventions such as cuddling or topical anesthetic (Harrison et al. 2016).
It is to be hoped that the AAP will ignore the suggestions of the INSIGHT authors and that adverse elements of the INSIGHT interventions will not be incorporated into parenting habits.

Literature:

• Guóth-Gumberger M: Gewichtsverlauf und Stillen. Dokumentieren, Beurteilen, Begleiten. [German; in English: Weight development and Breastfeeding. Recording, Evaluation and Follow-up]. Mabuse, 2011. ISBN 978-3-940529-89-3., p.104.
• Harrison D, Reszel J, Bueno M, Sampson M, Shah VS, Taddio A, Larocque C, Turner L: Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD011248.
• McKenna JJ, Gettler LT: There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatrica 2016;105 (1):17-21.
• Walker M: Breastfeeding Management for the Clinician, 2016, Jones and Bartlett Publishers, 4. ed., p. 642.
• World Health Organization: Exclusive breastfeeding to reduce the risk of childhood overweight and obesity. Biological, behavioural and contextual rationale. http://www.who.int/elena/titles/bbc/breastfeeding_childhood_obesity/en/, 2014.

This study purports to be a randomized controlled trial of infant-parent room sharing and, in fact, was a randomized controlled trial that sought to modify the sleep habits of parents with young infants through an educational intervention. However, the intervention failed, and the treatment and control groups ended up having the same rate of same-room sleeping with babies. Rather than learning from the failure to evince a change in parental behavior and redesigning a more effective intervention to achieve better compliance (and thus a distinction between treatment arms in sleep habits), the authors instead decided to analyze the differences in outcomes between those who chose to sleep in the same room with their infants and those who chose to sleep apart. First, these two groups looked differently on observable factors--the room sharers were less white, less educated and poorer on average--all factors that may affect child sleep quality through stress and schedule channels that are independent of which room the child is in. Second, the very fact that the intervention did not work to create behavioral differences among the groups suggests that reverse causation is probably a very important factor: Namely, it is the poor sleeping infants who -- despite professional advice -- who end up in their parents' bedrooms. Thus, it is poor sleep rhythms that are the cause, most likely, not the effect, of co-sleeping. It is concerning that the authors even mention their randomized trial, as if it lends causal robustness to a study that is, in fact, plagued by all the endogeneity of any casual correlation in observational data.