Blair, P.S., P. Sidebotham, A. Pease, and P.J. Fleming. 2014. “Bed-Sharing in the Absence of Hazardous Circumstances: Is There a Risk of Sudden Infant Death Syndrome? An Analysis from Two Case-Control Studies Conducted in the UK.” PLOS ONE 9(9): e107799.

This study combines individual-analysis of two population-based case-control studies from five English health regions between 1993 and 1996. This includes 400 SIDS infants and 1,386 controls comparable for age and time of last sleep.

Objective: to assess the risk from bed-sharing when done in the absence of hazardous circumstances to understand its risk relative to other infant sleep locations.

“Hazardous circumstances” was defined as sofa-sharing, alcohol consumption and smoking

KEY FINDINGS:

• Bed-sharing in the absence of hazardous circumstances did not pose an increased risk of SIDS. In infants under the age of 3 months the same proportion of SIDS and control infants bed-shared in the absence of hazardous conditions with no significant difference.
• Unexpectedly, safe bed-sharing in infants older than 3 months was found to be protective.
• Risks from hazardous bed-sharing are significant, even though the mechanisms are often not fully understood.
• Blanket advice against bed-sharing on the potential risks it poses does not reflect the evidence. Campaigns against bed-sharing unjustly stigmatises and condemns bed-sharing parents. It would be more effective and accurate to inform families as to how to bed-share safely, especially considering the positive relationship between bed-sharing and breastfeeding, and this study’s finding of a protective impact of bed-sharing beyond 3 months postpartum.

STRENGTHS

This study includes a large epresentative population sample.

LIMITATIONS

This study involves secondary analysis of observational data that are relatively old and the risks posed by different infant sleep locations may have changed over this period. There was a lack of data regarding parental drug consumption, another serious hazard risk when bed-sharing.

Brand, S. et al., 2014. Associations between Infants’ crying, sleep and cortisol secretion and mother’s sleep and well-being. Neuropsychobiology, 69(1), pp.39–51.

Questionnaires were completed by 24 mothers of infants. The infant’s sleep was objectively measured with actigraphs. Saliva samples were taken from infants shortly after waking in the morning. This was repeated after four weeks.

Objective – to investigate the link between cortisol secretion, crying and infant sleep inferred by the relationship with the psychological well-being of the mother and her sleep.

KEY FINDINGS:

• Infant morning saliva cortisol levels, sleep disruption and crying intensity were a strong predictor of maternal sleep and psychological well-being.
• The duration or volume for which the infant cried had a low predictive value
• Infant crying has a strong negative impact for the well-being for the family, with a greater overall strain and a higher risk of mother developing depressive symptoms. Fragmented infant sleep is the most important risk factor.

Campbell-Yeo, M.L. et al., 2014. Co-bedding Between Preterm Twins Attenuates Stress Response After Heel Lance: Results of a Randomized Trial. Clinical Journal of Pain, 30(7), pp.598–604.

Randomised control trial of preterm twins. Study is based on premise of several studies that support that intrauterine adaptation of the twins to one another extends to the extrauterine environment having discovered a strong co-regulatory bond between co-bedded infants.

Objective – to see whether co-bedding preterm infants reduces stress response to a common and mildly stressing medical procedure. Previous studies have found mother-infant contact reduces the stress response to heel lance. The authors of this study hypothesised a similar effect with twin-twin contact.

Methods — Infant stress was measured by taking salivary cortisol levels before and after heel lance in both co-bedding and non-bedding preterm twins.

Outcomes — Despite conducting research in a clinically-driven environment the study gathered significant results.

KEY FINDINGS:

• Average mean salivary control readings were the same for both co-bedding and non-co-bedding groups prior to heel lance. However measurements taken 20 minutes after the heel lance procedure were almost 50% lower in the co-bedding group (0.23 [0.12, 0.37]; 0.28 [0.25] vs 0.29 [0.19, 0.57]; 0.50 [0.73]). This is statistically significant in both parametric and nonparametric analyses, even when adjusted for factors such as postgestational age.
• These results indicate that there is a more highly regulated stress response through the heel lance procedure amongst pre-term cobedding twins, given a “significantly faster ability to return to baseline physiological parameters after heel lance in preterm twins who are co-bedding” when compared to infants undergoing standard care.
• The authors posit that this could be a result of coregulation with a twin that has not been subjected to heel lance decreasing the stress response of the infant that has undergone the procedure. It could also be because of skin-to-skin contact acting as a sensory reward to the infant, akin to the sucrose reward normally given to infants after stressing procedures.　

LIMITATIONS

There was a wide variation in infant cortisol levels. Whether infants have identifiable circadian rhythms could be a factor in this, which could influence the results both before and after depending on when the procedure occurs. However the study attempted to collected morning samples only to try to reduce this.

It is difficult or impossible to differentiate pain from stress in infants. Cortisol is released in response to both.

Staff conducting the procedures were unable to be blinded to the study intervention. Potentially this could subconsciously impact their care for different sets of twins. However the similarity in baseline salivary cortisol would suggest otherwise.

Chiu, K. et al., 2014. Are baby hammocks safe for sleeping babies? A randomised controlled trial. Acta paediatrica (Oslo, Norway: 1992), 103(7), pp.783–787.

Randomised control trial of full-term 4-8 week old infants, sleeping in either hammocks (n=14) or standard bassinets (n=9).

Objective – to investigate the safety of hammocks for infant sleep, after two instances of deaths in baby hammocks raised international concern in 2009. There have been concerns surrounding the curve of the hammock causing flexion of the infant’s head, which can compromise the upper airways. Sleep state, oxygen desaturation (and mean haemoglobin oxygen saturation), apnoea and hypopnoea were analysed in both groups.

KEY FINDINGS:

• No effect of sleeping in a hammock upon infant breathing or oxygen levels.
• Hammocks were associated with shorter duration of infant sleep. This could be due to most of the infants being new to baby hammocks (83%).
• However sleep was more efficient in hammocks and the number of awakenings per hour was similar in both groups.
• When used correctly hammocks are not associated with increased risk.
• The brand of hammock used accommodated the infant head and the upper airways were not compromised.
• Once infants can roll over the study does not recommend hammocks for unsupervised sleep as it would be particularly difficult for an infant to change into a more safe position once prone. In the two 2009 cases of infants dying in baby hammocks, both had rolled over.

LIMITATIONS:

This study only used a very small sample size of 23 infants. They also only used one type of baby hammock (Natures Sway Baby Hammaock). This does not represent the full range of hammocks. The study only monitored the infants for a short period of time during the day. Future studies could investigate longer periods of nighttime sleep. The study was also conducted at a general practice clinic, which perhaps is not best environment in which to replicate the normal home setting.

Colvin, J.D. et al., 2014. Sleep environment risks for younger and older infants. Pediatrics, 134(2), pp.e406–12.

Cross-sectional study of sleep-related infant deaths between 2004 and 2012.

Objective – to identify multiple elements of a safe sleep environment and their relationship with age. Data was gathered from the National Center for Review and Prevention of Child Deaths (NCRPCD) Case Reporting System database between 2004-2012.　

Infants were divided into two groups, younger (0-3 months) and older (4 months to 364 days).

KEY FINDINGS:

• Risk factors for 0-3 month-old infants are different to those aged 4 months to one year.
• The younger group of infants were more likely to die whilst bed-sharing (73.8% vs 58.9%, P<0.001) and sleeping in an adult bed or on a person (51.5% vs 43.8%, P<0.001).
• Younger infants were more likely to be placed in nonsupine positions to sleep (40.1% vs 35.9%, P<0.001) Whilst older infants were more likely to be found sleeping prone (42.4% vs 36.6%, P<0.001).
• The older group of infants were more likely to be found prone, having changed position from nonprone to prone (18.4% vs 13.8%, P<0.001). They were also more likely to be found with objects such as stuffed animals or blankets in their sleep environment (39.4% vs 33.5%, P<0.001) but not pillows, bumper pads, clothing and other objects.
• There were also differences in sleep environment risks between minority groups: “African-American infants who died were more likely to bed-share and have an object in their sleep environment. African-American and Latino infants were more likely to be placed in a nonsupine position and be placed somewhere other than a crib, bassinett or playpen”. This suggests that there are differences in practices and behaviours that are culturally formed.
• Dangers in the sleep environment are strongly associated with asphyxia risks to which the infant is particularly vulnerable at their stage in development.

STRENGTHS:

There is a consistent and objective means of classifying a wide range of elements surrounding infant deaths using a standardised data dictionary and data codebook. There was a very large dataset (n=8207) which is beneficial for making more meaningful and generalisable findings.

LIMITATIONS:

As in all studies conducted from information gathered from a large database by multiple individuals it is very difficult to be assured of consistent records. The participation in the database is voluntary which could also create bias in the results. It would have been beneficial to also have a control group with which to understand the differences in the prevalence of risk factors in these age groups in infants that have not died. Therefore one could see whether the variation in practices is unique to the infants that have died or is consistent amongst all infants at that age.

McDonnell, E. & Moon, R.Y., 2014. Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling. Journal of Pediatrics, 164(5), pp.1152–1156.

Retrospective review of incidents (n=36) reported to the Consumer Product Safety Commission (CPSC) between 2004 and 2012.　

Objective – to understand the risks of swaddling and associated sleep practices.

KEY FINDINGS:

• All 12 incidents where ordinary blankets were used for swaddling resulted in death. 7 of these deaths were due to lying prone, 6 of which had rolled over in their sleep. Four others died from soft bedding leading to suffocation, mechanical asphyxia and hyperthermia. Only one of these infants had no known environmental risk factor.
• Wearable blankets were responsible for 1 death, 2 injuries and 2 potential injuries. Both the injuries involved the zipper causing tooth extraction and the potential injuries were related to the zipper causing a choking hazard.
• Swaddle wraps were responsible for 8 deaths and 10 potential injuries. These were largely associated with dangers caused when the swaddle wrapped around the infant’s face when the wrap came undone.
• On the whole SUDI in swaddled infants is rare.
• It is highly recommended that swaddling end once the baby can roll.
• Removing soft bedding and bumper pads reduces risk of death or injury.

LIMITATIONS:

The source of the data is the Consumer product Safety Commission, which means that all the incidents are the product of self-reporting. This creates bias in the data. There is also uncertainty regarding the brands of swaddling items involved in each case, which could also be illuminating.

Rechtman, L.R., Colvin, J.D., Blair, P.S. and Moon, R.Y. 2014. “Sofas and Infant Mortality.” Pediatrics 134(5): e1293–1300.

Analysis of the data for the 1,024 infant deaths on sofas from 24 states between 2004 and 2012 gathered from the National Center for the Review and Prevention of Child Deaths Case Reporting System database.

As sleeping on sofas poses particular risk of sudden infant death and other sleep-related deaths, this study aims to understand the factors associated with infant deaths on sofas.

KEY FINDINGS:

• Sofa deaths made up 12.9% of sleep-related infant deaths. Deaths on sofas were more likely than deaths in other locations to be classified as accidental suffocation or strangulation or ill-defined cause of death.
• Infants that died on sofas were more likely: of non-Hispanic white ethnicity, have objects in their environment, be surface sharing with another person, be found in a new sleep location and have had prenatal smoke exposure.
• Sofa sharing itself is a very hazardous sleep surface and is associated with many SIDS risk factors. These include surface sharing, being found nonsupine, changing sleep location and experience of prenatal smoke exposure.

STRENGTHS

The databse used captures a wide-range of important information on child deaths in one place. The database is also expanding to new states, expanding the data range available for analysis, improving data quality. This increases the ability for the database to broaden and identify risk factors for all types of infant deaths.

LIMITATIONS

The system is voluntary, which introduces bias and subjectivity in data reporting. There is also the persistent inconsistency in classifying and coding for accidental suffocation, SIDS, SUDI and unknown or ill-defined cause of death. However this study avoided this pitfall by studying all infant deaths on sofas, lessening the importance of differentiating between these categories. The data regarding the final sleep of SIDS infants were also quite limited, lacking information such socioeconomic status and specific circumstances.

Salm Ward, T.C. 2014. “Reasons for Mother-Infant Bed-Sharing: A Systematic Narrative Synthesis of the Literature and Implications for Future Research.” Maternal and Child Health Journal: 675–90.

Systematic review of 34 international studies between 1990 and 2013

Objective – to understand reasons for mother-infant bed-sharing, including the reasons parents bed-share, the cultural context of bed-sharing and implications of this for interventions and future research.

KEY FINDINGS:

• Main themes surrounding reasons for bed-sharing included (from most to least cited): breastfeeding, comforting, better/more sleep, monitoring, bonding/attachment, environmental, crying, tradition, disagree with danger and maternal instinct. Many of these themes are inter-related, such as crying and disagreeing with danger could implicate some combination of circumstances that may lead a family to choose to bed-share. They could also be due the ways in which themes were coded.
• In the future, in addition to noting the reasons parents give, it could be useful to rate the importance of each factor.
• Future research should examine parents’ decision-making process on infant sleep location, such as how sources of advice are weighed. Public health interventions should be tailored to the population they seek to target.

STRENGTHS

This is a useful synthesis that could be a good basis for future development and research, and identifies areas for exploration in bed-sharing interventions.

LIMITATIONS

Due to the nature of qualitative data it cannot be replicated, added to another or transferred. Only one author determined eligibility and extracted the data, which could introduce systematic error. This analysis was also unable to determine the quality of the findings related to bed-sharing. In thematic analysis it can be difficult for readers to understand how and at what stage themes were identified. Themes were not stratified by demographic characteristics other than race or ethnicity. It would have been useful to stratify reasons for bed-sharing by other demographic characteristics such as age, educational level or socio-economic status.

Salm Ward, T. C, and Doering, J.J. 2014. “Application of a Socio-Ecological Model to Mother-Infant Bed-Sharing.” Health education & behavior: the official publication of the Society for Public Health Education 41(6): 577–89.

This study reconceptualises 16 studies in the light of the socio-ecological health model.

Objective – to understand variation in bed-sharing between different ethnic or racial groups within a population, given its potential risks, in order to be able to design more successful future public health interventions.

Results were interpreted with a five-level influence socio-ecological model: infant, maternal, family, community and society and the historical context of race.

KEY FINDINGS:

• Almost all the factors associated with infant, family, community and society and historical context of race were significant but results were inconclusive between studies or not significant.
• Maternal level factors were inconclusive for maternal age, breastfeeding, depression, sleep position and substance use. However there was a higher likelihood of bed-sharing associated with infant bedding practices. Bed-sharing was associated with more bedding, for example using quilts, duvets or multiple layers, irrespective of room temperature. This is particularly important given recent increases in rates of accidental suffocation and strangulation in bed.
• Amongst community/society-level factors, lower income level, lower socioeconomic status and fewer than the recommended number of well-child visits were associated with a higher likelihood of bed-sharing.
• The historical context of race did not examine maternal-level factors sufficiently for this study.
• The most conclusive evidence for influence among black families may be maternal-level factors such as overbedding when bed-sharing. This study suggests that the racial disparity in SIDS rate could be due to differences in bedding, some studies finding that there are race-based differences in the understanding of the concept of “firm” bedding. Equally race and ethnicity can also provide different cultural beliefs and practices influencing bed-sharing behaviours and its prevalence
• Campaigns regarding bed-sharing prevalence should strategically address each level of the socio-ecological level and should be tailored to the needs, experiences and beliefs of minority groups.
• Campaign messages need to be more complex than to rail against bed-sharing, but provide information as to how to practice it safely.

Tully, K.P. & Ball, H.L., 2014. Maternal accounts of their breast-feeding intent and early challenges after caesarean childbirth. Midwifery, 30(6), pp.712–719.

Study of breastfeeding intention and infant feeding after caesarean section amongst mothers in a postnatal unit in Northeast England between February 2006 and March 2009.

Objective – creastfeeding outcomes are worse after caesarean section compared vaginal birth for both biological factors. This study investigates the reasons and reality of this from the maternal perspective, so as to better understand and improve breastfeeding initiation rates in this important group of mothers. Interviews were conducted with 115 mothers at a postnatal unit on average 1.5 days after caesarean section birth.

KEY FINDINGS:

• Caesarean section delivery compromises the mother’s ability to breastfeed their baby.
• Whilst breastfeeding was frequent overall, infrequent breastfeeding was associated with infant-only reasons for breastfeeding intent (seven out of 22) in comparison to women who also raised self-advantages of breastfeeding (0 out of 20), p=0.0092 (Fisher’s Exact test).
• Of the women who were breastfeeding in hospital, the majority planned to continue. However mothers whose motivations were also infant-only were much more likely to plan to discontinue breastfeeding in hospital (11 of 40) compared to those who gave maternal inclusive reasons (2 of 46)(p=0.005, Fisher’s Exact test).
• The majority of mothers (71.8%, 61 of 85) had issues breastfeeding during their postnatal stay in hospital.
• Night-time feeding was most problematic for the mothers with caesarean section deliveries, as they had compromised mobility and needed assistance to breastfeed.
• Incision pain and limited mobility from the operation were common features in maternal descriptions of breastfeeding difficulties associated with the caesarean section.
• The authors suggest rules prohibiting overnight guests are disadvantageous for assisting breastfeeding and future breastfeeding promotion would benefit from an emphasis upon maternal benefit.
• They also advocate babies being accessible to mothers, for which they propose the use of side-car cots that attach to the maternal bed instead of stand-alone bassinets.
• Raising awareness about the infant health benefits of a labour-induced birth could help increase rates of breastfeeding. They suggest that obstetricians should include breastfeeding and post-caesarean morbidity amongst the risks of caesarean section births that they routinely mention to women.

STRENGTHS:

The non-leading interview style means that the responses were varied and as unique as possible. The responses are coded in such a way that the study is both qualitative and quantitative.

LIMITATIONS:

There is no comparison group of vaginal delivery mothers in the same community. The results of the study may not be generalisable to caesarean section mothers in Baby-Friendly hospitals in which staff are trained to assist maternal breastfeeding successfully.

Volkovich, E. et al., 2015. Sleep patterns of co-sleeping and solitary sleeping infants and mothers: A longitudinal study. Sleep Medicine, 16(11), pp.1305–1312.

Questionnaires, sleep diaries and nighttime actigraphy was conducted amongst 150 healthy married couples expecting their first child (singleton). Parents were recruited during pregnancy and visited during pregnancy, at three and at six months postpartum for monitoring.

Objective – to objectively investigate the “concomitant and predictive relationships’ of mother-infant sleep patterns and arrangements. Of particular interest was the difference in quality and quantity of sleep between co-sleeping and solitary sleeping dyads, whether there is a predictive link associated with maternal sleep pattern and arrangement pre- and post- partum. They also investigated whether there is a bi-directional relationship between infant and maternal sleep at three and six months postpartum and sleeping arrangement.

KEY FINDINGS:

• Maternal age is positively associated with infant’s longer actigraphic sleep in minutes at three months (r=0.25, p<0.01), but negatively associated with subjective sleep quality at three months (r=-0.24, p<0.01).
• Maternal education is positively correlated with higher maternal actigraphic longest sleep periods without waking.
• Measures of depression and anxiety were not associated with any sleep measures. However solitary sleeping arrangements were associated with higher scores on the Edinburgh Postnatal Depression Scale at three months (rho=-0.20) and higher Beck Anxiety Inventory scores at six months (rho=-26, p<0.005).
• Breastfeeding at three and six months was associated with more fragmented sleep for infants and mothers, both actigraphically and in the self-reported sleep-diaries.
• There was no significant difference in objective sleep measures between co-sleeping and solitary sleeping infants at three and six months postpartum. However co-sleeping mothers reported more wakings in their sleep diaries than solitary sleeping mothers.
• Co-sleeping mothers objectively and subjectively had significantly worse sleep than their solitary sleeping counterparts at three and six months. However they suggest that this could be because these mothers already have worse sleep during pregnancy.
• Whilst self-reported sleep quality was worse in co-sleeping mothers at three months there is no significant difference at six months in sleep quality despite having more night-wakings than solitary sleeping mothers.
• This study found predictive links between maternal prenatal sleep patterns and sleeping arrangements at six months postpartum. Mothers with more frequent and longer duration night-wakings in the third trimester were more likely to co-sleep with their infants later on.
• Breastfeeding as linked to lower subjective and objective infant and maternal sleep quality at both three and six months postpartum. Breastfeeding was also predictive of co-sleeping at six months, but not at three months.

LIMITATIONS

The sample is of relatively high cultural homogeneity, having been conducted in Israel. This means it is unlikely to be generalisable. Much of the experience of sleep is due to culturally formed expectation, which means that the culture is significant in the reporting of the results. The study recognises that it would have been helpful to evaluate the maternal reasons for co-sleeping. There is also only a small sample of bed-sharers in the sample (n=7) that is unrepresentative of this demographic. They also do not give a means of representing the frequency of co-sleeping, as in most cases it is a continuous measure.

Yoshida et al. 2015. Assessment of nocturnal sleep architecture by actigraphy and one-channel electroencephalography in early infancy. Early Human Development. 91(9):519-526

A Japanese study looking at the characteristics of different sleep patterns in infants by simultaneously using two devices; actigraphy (to monitor movements) and EEG (to measure brain waves). Data was collected whilst babies slept at home.

The study reported results from 27 infants (13 boys and 14 girls) at the same conceptional age of 3-4 months who provided at least 3 days of usable data.

Among the 27 study subjects, there were 14 infants (52%) who were exclusively breastfed. Of the remaining 13 infants, 10 were fed mixture of formula and breastmilk, and 3 were fed formula only.

KEY FINDINGS:

• Some babies who appeared to sleep through the night, (because they were not moving) were actually awake according to their brain waves. The majority of these babies were formula-fed.
• Some babies aroused and cried/fussed for less than 10 mins (called weak signallers based on their level of movement). These babies showed the strongest sleep cycles (experiencing ‘proper’ sleep) according to their brain waves. The majority of these babies were breastfed.
• A third group cried/fussed more than 10 mins (strong signallers-giving off lots of signals that they are not asleep) and had reduced sleep cycles according to their brain waves (poor quality sleep).

STRENGTHS:

By combining actigraphy and EEG data the results show that we cannot assume that babies who are quiet all night with little movement are experiencing good quality sleep.

LIMITATIONS:

Fifteen infants (56%) were co-sleeping with their parent(s) in the same bed from sleep onset until morning, and 12 of the 14 (86%) exclusively breastfed infants were co-sleeping. Further investigation is needed to ascertain the role of co-sleeping in infant sleep quality.

Due to small participant numbers, the mixed-fed infants and the exclusively formula-fed infants were grouped together. Mothers who mixed-fed their infants were not asked to report the amount of breast or formula milk given, thus the influence of formula milk on sleep may have been overestimated.

Authors discussed the limitations of using portable measuring devices in participants’ homes.

COMMENTS:

Despite the moderate number of infants involved in the study, the findings showed that the two devices used produced different pictures of what was happening during infant sleep. This highlights the limitations of other studies that rely only on actigraphy or behavioural data to determine infant sleep-wake cycles and sleep quality.

Ball, H.L., Howel, D., Bryant, A., Best, E., Russell and Ward-Platt, M. 2016. “Bed-Sharing by Breastfeeding Mothers: Who Bed-Shares and What Is the Relationship with Breastfeeding Duration?” Acta Paediatrica, 105(6): 628-34.

Randomised breastfeeding trial of 870 mothers, recruited mid-pregnancy. Weekly records were taken of breastfeeding and bed-sharing behaviour for 26 weeks postpartum. Strength of prenatal breastfeeding intent was recorded at recruitment using Likert-type scales.

Objective – to investigate the association between breastfeeding duration and bed-sharing frequency amongst women expressing a prenatal intention to breastfeed.　

KEY FINDINGS:

• There was insufficient data to classify a bed-sharing pattern in 22% of mothers. The remaining participants, 44% rarely or never bed-shared, 28% did so intermittently and 28% bed-shared often. Marital status, income, infant gestational age, maternal age and delivery mode did not differ significantly between these three groups.
• Participants who bed-shared often were more likely to report strong intent to breastfeed prenatally (70% vs 57% and 56%) and attached high prenatal importance to breastfeeding (95% vs 87% and 82%).
• Only 15 of the 870 women (2%) with prenatal intention to breastfeed never slept with their baby in the first 24 weeks postpartum.
• The most striking result was the finding that more women who bed-shared frequently were breastfeeding at 6 months (p<0.0001) than those who intermittently, rarely or never bed-shared.
• Mothers that bed-shared more often were more committed to breastfeeding intent, more highly educated and less likely to be white. White ethnicity has previously been associated with a significantly shorter duration of breastfeeding. The relationship between ethnicity and bed-sharing could complete this picture, but further research would be needed.
• This study suggests that recommendations to avoid bed-sharing impede the achievement of breastfeeding goals, causing unintended harm to infant and maternal well-being.

LIMITATIONS

Only a small proportion of this study identified as an ethnic minority, which could weaken the findings regarding the relationship between non-white ethnicity, bed-sharing and breastfeeding intent. Missing data in this study limited the detail of the analysis the authors hoped to achieve, resulting in an underrepresentation of younger mothers and mothers from lower income households.

Crane, D., and Ball, H.L. 2016. “A Qualitative Study in Parental Perceptions and Understanding of SIDS-Reduction Guidance in a UK Bi-Cultural Urban Community.” BMC pediatrics 16(1): 23.

In-depth narrative interviews conducted with 46 mothers (25 white British origin and 21 Pakistani) of 8-12 week old infants recruited from the pool of participants in the “Born in Bradford” cohort study.　

Objective – to understand the differences in implementation of SIDS-reduction guidance to understand the contrasts in SIDS rates and infant care practices between white British and South Asians.

KEY FINDINGS:

• All mothers were aware of SIDS-reduction guidance from antenatal and postnatal interactions with health care providers.
• Pakistani mothers tended to dismiss guidance as irrelevant to their cultural practices. However many SIDS-reduction practices were already part of normal Pakistani infant care, such as supine sleep, room-sharing, and avoiding alcohol, smoking and sofa-sharing. As many of the aspects of the guidance were irrelevant to them they felt it was not directed to them and were more likely to dismiss guidance that conflicted with their traditional beliefs, including bed-sharing, pillow use and overheating.
• White British mothers dismissed, adapted and adopted aspects of the guidance to suit their parenting style and personal circumstances.
• Some mothers misunderstood or misinterpreted the guidance and explained infant care behaviour according to their own circumstances.

Gradisar et al. 2016. Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics. 137 (6): e20151486-e20151486.

A study was carried out to evaluate the effects of behavioral interventions on the sleep/wakefulness of infants, parent and infant stress, and later child emotional/behavioral problems, and parent-child attachment.

KEY FINDINGS:

Significant interactions were found for sleep latency (P < .05), number of awakenings (P < .0001), and wake after sleep onset (P = .01), with large decreases in sleep latency for graduated extinction and bedtime fading groups, and large decreases in number of awakenings and wake after sleep onset for the graduated extinction group.

Salivary cortisol showed small-to-moderate declines in graduated extinction and bedtime fading groups compared with controls. Mothers’ stress showed small-to-moderate decreases for the graduated extinction and bedtime fading conditions over the first month, yet no differences in mood were detected. At the 12-month follow-up, no significant differences were found in emotional and behavioral problems, and no significant differences in secure-insecure attachment styles between groups.

STRENGTHS: Mixed method approach. Follow-up data was gathered at 12 months.

LIMITATIONS: The findings of this study were based on the results from a small participant sample size of only 43 infants who were then randomized into one of the three conditions; graduated extinction (n = 14), bedtime fading (n = 15), or sleep education control (n = 14). A high proportion of infants did not complete the study which decreases the sample size further. Participants were highly educated and well off. Infant sleep location was not considered.

COMMENTS: The initial sample recruitment did not meet the criteria of the power calculation to detect a large effect size, so any significant findings may be false positives, and lack of differences may be false negatives. The results are therefore preliminary and should not be relied on for recommendations.

McKenna, J.J. & Gettler, L.T., 2016. There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatrica, International Journal of Paediatrics, 105(1), pp.p.17–21.　

This is a commentary article reviewing the information surrounding breastfeeding and infant sleep with an evolutionary perspective.

The authors argue that bed-sharing and breastfeeding as inextricable, the former doubling or tripling the latter. The benefits that increased breastfeeding confers they see as products of developmental adaptation.

They begin by discussing the role attachment by constant contact and co-sleeping plays in lactogenesis and breastfeeding. They believe evolutionarily this is developmentally significant behaviour. With increased breastfeeding through bed-sharing for example there is increased growth in white matter growth and greater cognitive development.

Furthermore they see breastfeeding as significantly more important in human infants than any other due to our immature developmental condition at birth as a result of our large crania and narrow pelvises. They also discuss maternal benefits, including the lower rates of breast cancer amongst breastfeeding mothers.

Thompson, E.L. & Moon, R.Y., 2016. Hazard Patterns Associated With Co-sleepers. Clinical Pediatrics, 55(7), pp.645–649.

Retrospective review of incidents associated with co-sleepers reported to the Consumer Product Safety Commission. This includes 6 deaths and 20 injuries.

Objective – previous studies have investigated the relative safety of co-sleepers (bed-side co-sleepers or in-bed co-sleepers) compared to other means of sleeping, but this study wanted to understand those risks that are associated with them and their hazard patterns.

KEY FINDINGS:

• Half the deaths were associated with the same model of in-bed co-sleeper. The other half of the deaths was associated with bedside co-sleepers from a single manufacturer. Two thirds of the deaths had additional infant risk factors.
• Two thirds of the injuries were associated with bedside co-sleepers, the rest were associated with in-bed co-sleepers.
• Entrapment was the most common injury (60%).
• Suffocation was the second most common injury (35% of injuries).
• In 45% of the injuries the infant was found having fallen, or falling out of bed, thought to be through rolling over in their sleep.
• In 45% of injuries the infant had become trapped in gaps and spaces created by the co-sleeper.
• Improper use or assembly of the co-sleeper caused 45% of injuries.
• The authors emphasise that deaths from co-sleeper use continue to be rare.
• The study recommends that parents opting for co-sleepers should make sure to assemble their product correctly and to never use a second-hand product.

LIMITATIONS:

The data from the Consumer Product Safety Commission in all reported on a voluntary basis by anyone involved in the incident, including emergency or insurance staff, manufacturers or the parents. This could bias the data and is also very anecdotal. It also means that the level of demographic or environmental detail recorded in each case is very variable. The authors recognise that this study is an underrepresentation of the actual prevalence of deaths in co-sleepers, due to the voluntary nature of reporting. There is a small sample size of 26 cases, from which it is difficult to make powerful or meaningful generalisations.