Source: ISIS Co-Sleeping Image Archive

Yes, you read the title right.  I know, I know, one of the major risk factors for SIDS with bedsharing is having a premature baby.  But is that the whole story and should we be talking more about this issue for families who have a premature infant?  I will cover some science here, but I want to more open up a discussion, especially for those health care providers out there who follow this site.  I hope to cover four main areas and then leave the discussion open to everyone here.  I know that some will be appalled that we should even be talking about this, so let me start by saying that many families end up bedsharing with premature infants and so it should be our duty to explore this more and determine what the best course is for every individual family.  The following are the areas to be covered herein:

  1. Evolutionary-speaking, what other option is there?
  2. The importance of contact for premature infants.
  3. What do other countries do?
  4. What is the SIDS risk?
  5. Where does this leave us?

Evolutionary-speaking, what other option is there?

I always like to think of things historically first, even though our hope is that we can take what helped us thrive historically and then improve upon the rest.  With respect to premature infants, the improvements come from the medical care we can now provide which is essential to so many of their survivals.  However, as history has shown us, when we moved too far towards the medical, we saw problems that are now being addressed by the push for “kangaroo care” (which I will cover more in the next section).  Thus a delicate balance between our biology and technology seems to be the best approach when we look at how to care for premature infants.

Historically, premature infants would be consistently attached to their mothers (frankly, no real different from other infants) and this, as we now know, would have helped some survive (depending on many other factors).  This didn’t end at sleep and so families would sleep with their premature infants.  Of course, the largest distinction is the type of sleeping environment that one would have had historically (or in current traditional societies) versus our own in a modern world.  This leaves open the possibility that the act of sleeping next to a parent is not the increased risk, but rather the modern bedsharing environment.  This would mean that it would theoretically be possible to have a safe environment for bedsharing with a premature baby.  Thus there is nothing in our history that would suggest bedsharing with a premature infant is so dangerous as to outweigh the risks of sleeping apart from the infant or to outweight the potential benefits.

The importance of contact for premature infants

As mentioned above, kangaroo care has come back into fashion as a means of caring for premature infants as we learn how important it is for these infants to have as much skin-to-skin and physical  contact as possible.  There are times when this is not possible, but when it is, we have documented evidence of how much it improves various outcomes for premature infants, including diminished pain response (as pain is associated with negative outcomes for preterm infants)[1][2], lower rates of infection[3], and one meta-analysis identified the following benefits: lower mortality, increased exclusive breastfeeding, and decreased risk of neonatal sepsis, hypothermia, hypoglycemia, and hospital readmission[4].  Health-wise alone, clearly lots of physical contact is hugely important for premature babies’ well-being.

What about the effect on sleep?  We know that even intermittent kangaroo care results in better sleep organization and longer periods of quiet sleep for premature infants[5].  Importantly, this increase in deep sleep (which is thought to be important for development) occurs only during kangaroo care (i.e., the child placed supine on the parent’s chest), not just being in a parent’s arms[6].  Thus it would seem that kangaroo care is important not just for health outcomes, but actually for an infant’s sleep development and overall development as well.

What do other countries do and what is the SIDS risk?

The question becomes: How do parents cope with the infant’s need for kangaroo care with their own needs for sleep?  There has been concern over how parents can provide kangaroo care while still obtaining their own sleep needs (with the idea that parents must remain awake while the infant is in the kangaroo care position), especially as sleep deprivation can result in more stress for the parents which can in turn lead to less sensitivity.

In most of the Western world, most advice settles on parents taking turns sleeping with the infant and resting, but this is not always practical when there are other children and work that must be taken into account.  In Canada, it is simply not recommended for parents of preterm infants to bedshare (even in the discussion of how to bedshare safely), as is the case in the UK and in the USA.  Side cots and so on are considered the best alternative for all premature infants.

One country bucks this trend though: Sweden.  In Sweden, bedsharing is quite common and this does not deviate for preterm infants[7][8].   In one study[8], approximately 80% of families bedshared sometimes or always with their preterm infant when they were discharged from the hospital.  This is understood and all parents reported receiving advice on how to bedshare safely with a premature infant prior to discharge.  One might be tempted to look at Sweden’s SIDS risk and note that it is less than that of the USA and other countries who do not recommend bedsharing and think that this provides evidence that it’s not bedsharing pre se, but this would be wrong.

What is the effect on SIDS risk?

In the United States, extreme prematurity (24-27 weeks gestation) is associated with a 3-fold increased risk of sudden unexplained infant death[9], but prematurity remains a risk factor in and of itself, one that decreases as the infant reaches gestation.  The question is if prematurity interacts with bedsharing to increase the risk above and beyond what is already known.  One study out of NZ did examine this and indeed, bedsharing was found to be a much greater risk factor for preterm than term infants, in the realm of doubling the already doubled risk for prematurity[10].  However, statistics are actually relatively hard to find.

This leaves us with data from NZ (which unfortunately has some unique, cultural-level variables that impact their SIDS rates and factors, such as high poverty and marginalization within their Maori community, the community with the highest SIDS and bedsharing rates).  It is notable that Sweden – who does promote safe bedsharing – does have an independent risk of prematurity so it is not that prematurity is not a factor there.  Premature infants in Sweden are at approximately double the risk of dying from SIDS as term infants[11].

The paucity of appropriate data is important to consider, especially given the recent reanalysis of data using a syndemics approach which highlighted the lack of primary effect of bedsharing on SIDS and impact instead of variables associated with marginalization and lower socio-economic status.  In this vein, we should look at the clusters of individuals who have premature babies and the inherent risk of their social world.  For example, a minority woman with little access to health care in the United States is more likely to have a premature baby.  She is also more likely to smoke, have poor health herself, high stress levels during pregnancy, and so on.  These factors are all independent risk factors for prematurity and SIDS.  Prematurity is then also an independent risk factor for SIDS.  Combined, these may exacerbate risk of bedsharing to one that is much higher than it would be in a culture where prematurity is not so intricately linked to poverty.

Where does this leave us?

I believe we have to consider multiple areas here.  First, from what we can gather there is a potential for a confounding effect between bedsharing and prematurity, though the degree of this and how much of it depends upon other factors remains to be seen.  However, it is paramount that all families of premature infants be given safe bedsharing information as they do in Sweden given that many premature infants need such contact regularly and this can allow families to get much-needed sleep while providing the type of contact their premature infant requires.

Second, we have to weigh the risks versus the benefits.  In the case of premature infants, there are two elements linked to bedsharing that offer strong benefits: skin-to-skin contact and breastfeeding.  I have covered the importance of skin-to-skin contact above already.  For breastfeeding, we know that breastfeeding and bedsharing can be intricately linked with bedsharing being a positive tool for mothers to reach their breastfeeding goals[12].  We also know that breastfeeding is a key protective factor for premature infants, particularly on discharge, both generally and with respect to helping reduce the independent risk for SIDS[13][14].  Thus, if bedsharing safely increases the ability and duration of breastfeeding, it may counter the potential additional risk of bedsharing on SIDS given the positive effects on not only SIDS but all outcomes.

Third, we need to consider the reality for parents and our assessment of risk.  Premature infants require parents who are more sensitive and responsive to them in order to thrive.  The stress of caring for a premature infant is known to be great and lack of sleep is one thing that can increase our experiences and reactions to stress.  Parents who cannot sleep well may struggle to provide appropriate care for their premature infant and this is not something we want.  In Western culture, we seem to feel that we need to put the burden on parents to be perfect with respect to all risks, yet this is an impossibility.  We need to step back and ask parents what they need to provide the best (not ideal) environment that they can provide and then work with them there.  In many cases, bedsharing provides much-needed sleep and skin-to-skin contact seems to increase parental feelings of competence and reduce stress that is ongoing when caring for a preterm infant[5][8].  Unfortunately, in our society we have become so risk-focused that we have ignored the greater picture of the risks and benefits that actions can provide.  In turn, we overlook the potential unknown negative outcomes for an entire family when we fail to consider them as a unit worthy of our respect and consideration.

I don’t think there is one way forward from this, but I do feel that we need to be more open to meeting families of premature infants where they are.  If Sweden can tell us anything, it’s that there is at least the possibility that we can advocate for safe bedsharing for premature infants without the world collapsing.  Of course that comes with a host of other cultural differences (e.g., access to health care, differences in poverty), but they are ones that may help shift our thinking away from looking at the immediate risk factors and taking a more global view.

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[1] Pagni AM, Kellar S, Rood M.  Effects of kangaroo care on procedural pain in preterm infants: a systematic review.  Honours Research Projects 2017; 441.

[2] Johnston CC, Stevens B, Pinelli J.  Kangaroo care is effective in diminishing pain response in preterm neonates.  Archives of Pediatric and Adolescent Medicine 2003; 157: 1084-1088.

[3] Charpak N, Ruiz-Pelaez JG, Figueroa de C Z, Charpak Y.  Kangaroo mother versus traditional care for newborn infants ≤2000 grams: a randomized, controlled trial.  Pediatrics 1997; 100: 682-688.

[4] Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E, Kajeepeta S, Wall S, Chan GJ.  Kangaroo mother care and neonatal outcomes: a meta-analysis.  Pediatrics 2015; peds.2015-2238.

[5] Baley J.  Skin-to-skin care for term and preterm infants in the neonatal ICU.  Pediatrics 2015; peds.2015-2335.

[6] Bastani F, Rajai N, Farsi Z, Als H.  The effects of kangaroo care on the sleep and wake states of preterm infants.  The Journal of Nursing Research 2017; 25: 231-239.

[7] Welles-Nystrom B. Co-sleeping as a window into Swedish culture: considerations of gender and health care. Scand J Caring Sci 2005; 19: 354–60.

[8] Blomqvist YT, Nyqvist KH, Rubertsson C, Funkquist EL.  Parents need support to find ways to optimize their own sleep without seeing their preterm infant’s sleeping patterns as a problem.  Acta Paediatrica 2017; 106: 223-228.

[9] Ostfeld B, Schwartz-Soicher O, Reichman NE, Teitler JO, Hegyi T.  Prematurity and sudden unexplained infant deaths in the United States.  Pediatrics 2017; e20163334.

[10] Thompson JMD, Mitchell EA.  Are the risk factors for SIDS different for preterm and term infants?  Archives of Diseases in Childhood 2006; 91: 107-111.

[11] Alm B, Norvenius SG, Wennergren G, Skjærven R, Øyen N, Milerad J, et al. Changes in the epidemiology of sudden infant death syndrome in Sweden 1973-1996.  Archives of Diseases in Childhood 2001; 84: 24-30.

[12] Ball HL, Howel D, Bryant A, Best E, Russell C, Ward-Platt M.  Bed-sharing by breastfeeding mothers: who bed-shares and what is the relationships with breastfeeding duration?  Acta Paediatrica 2016; 105: 628-634.

[13] Schandler RJ, Shulman RJ, Lau C.  Feeding strategies for preterm infants: beneficial outcomes of feeding fortified human milk versus preterm formula.  Pediatrics 1999; 103: 1150-1157.

[14] Lechner BE, Vohr BR.  Neurodevelopmental outcomes of preterm infants fed human milk: a systematic review.  Clinics in Perinatology 2017; 44: 69-83.