To understand tension mothers experience when attempting to follow American Academy of Pediatrics safe sleep guidelines and enhancing infant and parental sleep.
Surveys and focus groups were conducted from November 2022 and March 2023 with United States-based English-speaking mothers of infants <6 months of age recruited via social media and who reported a nonrecommended sleep position and/or location ≥2 times the prior week.
Twenty-five mothers participated in focus groups and surveys. A total of 80% reported holding or rocking their infant to sleep; 76% fed their infant to sleep. Almost all were aware of the ABCs (Alone, Back, Crib) of safe sleep and intended to follow them before delivery. Many felt that ABCs were unrealistic and placed their infants in nonrecommended locations or positions because they perceived them as more comfortable and helping their infant fall and stay asleep. Mothers were more likely to use nonrecommended practices when they were awake or sleeping nearby and believed they could closely monitor their infant. Some questioned whether ABCs were the only way to achieve safe sleep. Some prioritized other safety concerns (eg, fall prevention) over sudden infant death syndrome or sudden unexpected infant death prevention. Mothers expressed confidence about getting their baby to sleep in general but were less confident that they could do this while following guidelines.
Despite awareness of the ABCs, mothers regularly engaged in nonrecommended practices with the goal of improving their own and their infant’s sleep. Interventions focused on improving infant and parental sleep while maintaining sleep safety are needed.
Comments
There's much more to it than tension.
Since the start of concerted public health efforts to reduce SIDS in the early nineties, anthropologists, sociologists, and other social scientists have studied the context and consequences of public health approaches intended to reduce SIDS (e.g. Hackett 2012). Using a range of approaches from large mixed-method cohort studies to in-depth ethnographic and comparative work anthropologists have documented how parents in western post-industrialised settings have implemented, interpreted, ignored, modified and rejected infant sleep safety guidance (e.g. Ball et al 2019). This work has highlighted the conflict parents experience between following safer sleep guidelines and meeting their babies’ night-time needs and offers rich understanding of night-time breastfeeding and sleep practices within US cultural settings and elsewhere. It also illuminates the cultural ideologies and power dynamics entailed in negotiating dominant Western paradigms of infant sleep and sleep safety (e.g. Tomori 2014; Harrison 2022). We have demonstrated repeatedly that idealised ‘safe sleep’ guidance offering parents no latitude to make informed decisions regarding their infants’ sleeping arrangements is frequently rejected by mothers. This rejection is driven by mothers who are a) breastfeeding and find it more manageable to do so with their baby next to them in the bed, and b) from cultural backgrounds that value and prioritise mother-baby sleep contact--which comprise the majority of cultures and populations of the world. There is an extensive body of peer-reviewed published work that previously identifies and addresses the tension ‘revealed’ in this article.
Yet this paper fails learn from, or mention, this broad range of academic work. We encourage readers of Pediatrics to access the extensive work of social scientists regarding infant sleep and sleep safety practices to gain more thorough insight into the ‘tension’ that exists for parents between achieving sleep and supporting infant sleep safety, driven by the mismatch between solitary sleep guidance and the evolved human infant need for closeness and frequent breastfeeding for survival and optimal human development (Barry 2021). As equity is the central priority of the 10 Essential Public Health Services, sleep guidance and interventions cannot afford to overlook the importance of the biological and cultural value of close contact and interconnections between sleep and breastfeeding. Social-science-informed approaches are urgently needed to advance health equity in infant sleep research, guidance, and practice.
Ball, H. L., Tomori, C., & McKenna, J. J. (2019). Toward an Integrated Anthropology of Infant Sleep. American Anthropologist, 121(3), 595–612. https://doi.org/10.1111/aman.13284
Barry, E. S. (2021) ‘Sleep Consolidation, Sleep Problems, and Co-Sleeping: Rethinking Normal Infant Sleep as Species-Typical’, The Journal of Genetic Psychology, 182(4), pp. 183–204. doi: 10.1080/00221325.2021.1905599.
Hackett, Martine (2012) Back to Sleep: Creation, conflict and consequences of a public health campaign. AkerdemicaVerlag, Saarbrucken.
Harrison, L. (2022). Losing sleep: risk, responsibility, and infant sleep safety. New York University Press.
Tomori, C. (2014). Nighttime Breastfeeding: an American Cultural Dilemma. Berghahn.
Response to Bartick: Babies can Sleep Safe and Sleep Well
We thank Dr. Bartick for her thoughtful comments.
The purpose of our qualitative article was to highlight some of the sleep challenges that parents face with their young infants. We believe that every parent wants their infant to be safe and to sleep well, and this is our goal as well. However, our study highlights that most parents do not know how to accomplish this.
Dr. Bartick asserts that, because parents in our study have described the safe sleep recommendations as “unrealistic,” the recommendations “must change.” She also suggests that the AAP should follow the lead of the UK, which has changed its recommendations regarding bedsharing and notes that there has been no decline in rates of sudden and unexpected infant death in the US since the AAP first recommended against bedsharing in 2016.[1]
We do not believe that our study, in which we held group discussions with 25 mothers, should be used to justify upending evidence-based recommendations for a safe sleep environment, which are based on case-control studies involving thousands of infants. Additionally, we would like to note that the UK has also not seen a decline in rates of sudden and unexpected infant deaths since 2014.[2] As pediatric clinicians and researchers, we also recognize that there are many evidence-based recommendations, including those to limit screen time, eliminate sugar-sweetened beverages, and use of car seats starting with their first ride home from the hospital, which may be difficult for some parents to follow with their children. Because some parents describe these recommendations as “unrealistic” does not mean that the recommendations must change or be wholly discarded as Bartick would suggest.
With regards to Dr. Bartick’s concern that we did not distinguish feeding types, this was a small qualitative study, and feeding type was not a focus of the study. However, we know from the discussions that our participants included parents who fed human milk and parents who fed formula.
Finally, Dr. Bartick states that parents should be provided with “realistic, physiologic, and safe alternatives.” Two studies have shown that parent-reported sleep quality is better when infants are independent sleepers, sleeping on a separate surface or location.[3,4] Parents reported increased sleep consolidation and decreased parent-perceived sleep problems. These results and the findings of our recent study align with our goals, which we expect are Dr. Bartick’s as well - to keep babies safe and ensure that all infants get the sleep they need.
References
1. TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016;138(5):e20162938. doi:10.1542/peds.2016-2938
2. The Lullaby Trust. SIDS & SUDC Facts and Figures. December 2023. Available at: www.lullabytrust.org.uk/wp-content/uploads/Facts-and-Figures-for-2021-released-2023.pdf. Accessed on Apr 23, 2024.
3. Paul IM, Hohman EE, Loken E, et al. Mother-Infant Room-Sharing and Sleep Outcomes in the INSIGHT Study. Pediatrics. 2017;140(1):e20170122. doi:10.1542/peds.2017-0122
4. Mindell JA, Leichman ES, Walters RM. Sleep location and parent-perceived sleep outcomes in older infants. Sleep Med. 2017;39:1-7. doi:10.1016/j.sleep.2017.08.003
Study demonstrates why ABC recommendations must change
ABM promotes physiological infant care, in which the normal mother-infant sleep physiology is sidelying breastfeeding with proximate sleep.2 This practice allows mothers and infants to get quality sleep and awake refreshed. Mothers in the study are describing normal physiology when they say that their infants can only sleep when being held, and that they and their infants sleep best when they sleep together.
The subjects in the study tell the authors exactly why ABC fails. Mothers say it is “unrealistic.” In other words, mothers cannot comply with ABC because it conflicts with normal mother-infant sleep physiology, evolved over millennia of human history.
The mothers in the study illustrated how ABC’s simplistic message could inadvertently encourage dangerous behavior. ABC implies that any surface besides a crib is equally bad, leaving mothers to sometimes turn to very hazardous situations to cope. This is precisely what mothers in this study did, sleeping with their infants on sofas, or placing their infants on pillows. The study actually illustrates how infants will continue to die under current AAP guidelines, because the ABC does not address the behaviors most likely to result in infant death, such as sofa-sharing. Mothers seek hazardous alternatives because ABC is “unrealistic,” yet realistic, physiologic, and safe alternatives are not provided. This study should be a wake-up call to shift immediately away from ABC, as other health authorities have done.2, 3
The study does not distinguish feeding types, a major flaw. Breastfeeding mothers sleep in a way that may protect infants from sleep-related death,4 whereas formula feeding mothers may sleep in way that might be potentially hazardous, such as putting their infants on pillows or near pillows.5 Separating breastfeeding mothers from their infants at night removes this protection and potentially increases the risk of death.2
To decrease infant deaths, campaigns for safe sleep should accommodate normal mother-infant sleep physiology, with an emphasis on safe bedsharing and avoiding hazards such as sofas and infants sleeping on pillows. If AAP is serious about reducing infant deaths, it must change its safe-sleep strategy as soon as possible to one that is evidence-based. AAP should review all the evidence in an unbiased fashion, using a new team who understands the importance aligning parents’ needs with normal physiology, instead of continually trying to alter ingrained normal human behavior in pursuit of an outdated objective that has repeatedly been proven to fail.
1. Moon RY, Carlin RF, Hand I, Task Force on Sudden Infant Death Syndrome, The Committee on Fetus and Newborn. Evidence base for 2022 updated recommendations for a safe infant sleeping environment to reduce the risk of sleep-related infant deaths. Pediatrics. Jul 1 2022;150(1):e2022057991.
2. Zimmerman D, Bartick M, Feldman-Winter L, Ball HL, Academy of Breastfeeding M. ABM Clinical Protocol #37: Physiological Infant care-Managing nighttime breastfeeding in young infants. Breastfeed Med. Mar 2023;18(3):159-168.
3. NICE (National Institute for Health and Care Excellence). Postnatal care [M] Benefits and harms of bed sharing: NICE guideline NG194. London: NICE; 2021.
4. Bartick M, Young M, Louis-Jacques A, McKenna JJ, Ball HL. Bedsharing may partially explain the reduced risk of sleep-related death in breastfed infants. Front Pedatr Sec. General Pediatrics and Pediatric Emergency Care. 2022.
5. Ball H. Parent-infant bed-sharing behavior : Effects of feeding type and presence of father. Hum Nat. Sep 2006;17(3):301-318.