In December 2014, the National Institute for Health and Care Excellence (NICE) issued updated recommendations for health professionals on sudden infant death syndrome (SIDS) and co-sleeping (sleeping with a baby on a bed, sofa or arm-chair) (NICE, 2014a). This was the result of a ‘rapid’ (year-long) review prompted by a study in BMJ Open that hit the headlines in 2013. The update forms part of NICE Guidance 37: Routine Postnatal Care of Women and their Babies, which should be familiar to all midwives, health visitors and GPs.
The new guidance advises that parents should be informed, during antenatal and postnatal contacts, of the statistical association between co-sleeping and SIDS, but does not tell parents to never sleep with their babies. The key message is that health professionals must give parents balanced information to help them make decisions about where their babies sleep (NICE, 2014b). Those parents who need the most careful guidance are those who smoke or did so during pregnancy—the association with SIDS is strongest in this group. Evidence also suggests a potential association between SIDS and co-sleeping for babies born prematurely, with low birth weight, or with parents who co-sleep after consuming alcohol or drugs, so these situations also warrant special attention.
The NICE emphasis on informed choice is a departure from previous national messaging around co-sleeping, which discouraged parents from sleeping with their babies (Department of Health, 2009), prompting many NHS Trusts to implement ‘never bed-share’ policies. Such approaches have been criticised for failing to provide parents with essential sleep safety information (Fetherston and Leach 2012; Ball and Volpe, 2013; Bergman, 2013; Bartick and Smith, 2014) especially given the large proportion of UK parents who occasionally, or regularly, spend all or part of the night sleeping with their babies (Blair and Ball, 2004; Bolling et al, 2007).
There are two reasons for this change: first, a rigorous analysis of the relationship between SIDS and co-sleeping across 12 international case-control studies and two individual patient data analyses did not find robust evidence of increased risk. Although an association between SIDS and co-sleeping was detected when all co-sleeping environments were considered as a whole (sofas, chairs and beds), the evidence that co-sleeping was causally linked to SIDS was not compelling. Although there is some evidence that co-sleeping on sofas is particularly hazardous (Blair et al, 2014; Rechtman et al, 2014), a lack of studies with sufficiently detailed data prohibited separate recommendations about bed versus sofa co-sleeping.
Second, there is growing recognition that many UK babies sleep with their parents at least occasionally, for a wide range of reasons, both deliberate and unintentional. The new guidance therefore begins by recommending that health professionals discuss the circumstances of co-sleeping with parents and carers, as individual families may need to consider different things. A recent systematic narrative review of 36 studies exploring why parents choose to sleep with their babies found that facilitating night-time breastfeeding was, by far, the most prominent explanation. In these circumstances, intentional co-sleeping allows mothers to accommodate their own need for sleep with their baby's need for frequent nursing. Other motivations included respecting cultural tradition, soothing infant crying, and protecting babies from environmental hazards (Ward, 2014).
There will be disappointment that these guidelines do not differentiate between breastfeeding and non-breastfeeding babies with regards to SIDS and co-sleeping—a feature of much panel discussion, as well as many stakeholder comments received in the consultation phase of this update (NICE, 2014c). Although there is some evidence that any association between SIDS and co-sleeping in the context of breastfeeding is small-to-non-existent, there were insufficient data addressing this relationship to underpin a specific recommendation (NICE, 2014a). As evaluation of the benefits of co-sleeping to breastfeeding were beyond the scope of this update, the panel recommended that this topic should be examined when the NICE guidance on breastfeeding is next updated (NICE, 2014d).
It is important to note that this guidance update was restricted to SIDS only, and did not cover accidental infant deaths, which sometimes occur in hazardous co-sleeping environments. Such deaths, although rare, have been previously linked with the intoxication of an infant's carer, and with makeshift, or unplanned, sleeping arrangements (Blair et al, 2009; Chu et al, 2015). In health professional training, and in discussions with parents, attention should be paid to awareness of accidents as well as to SIDS. To support health professionals who provide antenatal and postnatal infant care information to parents, NICE are evaluating and endorsing a selection of resources for use with parents, and in staff training for implementation of this guidance (NICE, 2014e).
As a topic-specific member of the panel, my remit was to present the views of parents who intentionally choose to co-sleep with their babies: my experience as a co-sleeping mother, and 20-years as a parent–infant sleep researcher, informed my contributions. Other topic-specific panel members presented the views of paediatricians, midwives, health visitors and parents bereaved by SIDS. Together with the standing members of the panel (representing a wide range of clinical, research and lay backgrounds) a consensus agreement for the recommendation was reached—health professionals should not be required by their Trusts to tell parents where babies must sleep, but should be encouraged to empower parents with information to make their own choices. BJM