When is it okay to risk a baby’s death?

All Alone

A new piece on NPR suggests that it’s okay to risk a baby’s death in order to bed share.

The piece asks Is Sleeping With Your Baby As Dangerous As Doctors Say? and answers by suggesting that the “right” kind of parents can bed share while the “wrong” kind of parents cannot.

Is the relative risk irrelevant? Is it only the absolute risk that counts? Who gets to decide?

Parents who drink or do drugs shouldn’t be sleeping with their babies because they could roll over onto their child. Babies who are born premature or whose parents smoke shouldn’t sleep in the parents’ bed because of potential respiratory problems. Suffocation can also happen when babies sleep on sofas because babies can be trapped between a parent and the cushions…

But what about the “right” kind of parents?

So far, only two studies have looked at this question. And doctors and families need to be careful with how they interpret these studies, says Robert Platt, a biostatistician at McGill University, who analyzed the studies for the AAP.

“The evidence is quite thin or weak,” he says. In both studies, the number of SIDS cases is small. One study of 400 SIDS had 24 cases in which that baby had shared the bed in the absence of parental hazards, and in the other study, there were just 12 of these cases out 1,472 SIDS deaths. In the latter study, some information about the parent’s drinking habits was missing and had to be estimated.

Nevertheless, the two studies came to similar conclusions. For babies older than 3 months of age, there was no detectable increased risk of SIDS among families that practiced bed-sharing, in the absence of other hazards.

Nevertheless? Pro-tip for the folks at NPR: when a study is underpowered, the results are not valid. You cannot use them to make recommendations. But let’s imagine for the moment that these statistics are accurate.

Even the “right” parents can still smother an infant less than 3 months old.

And for babies younger than 3 months?

“I would probably say there may be an increased for this group,” Platt says. “And if there is an increased risk, it’s probably not of comparable magnitude to some of these other risk factors,” such as smoking and drinking alcohol.

NPR includes a chart that attempts to distinguish when it’s okay to risk a baby’s death from when it’s not.

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The chart implies that tripling the risk of a baby’s death by bed sharing in the “right” situation is acceptable because the absolute risk is low — 1 in 16,4000. In other words, it purportedly doesn’t matter how much a particular maternal action increases the risk of death as long as the absolute risk is low.

Is that what we really believe?

Consider the case of infants and car seats. According to the Insurance Institute for Highway Safety, from 1975 to 2013, infant fatalities fell from 6/100,000 (1 in 16,7000) to 1.3/100,000 (1 in 76,900) while car seat use rose to 99% of children under age 1. So the risk of death from to a baby riding in a car without a car seat is LOWER than the risk of death from bed sharing.

If it’s the absolute risk that counts and not the increase in relative risk than mothers who don’t strap their babies into car seats are better mothers than those who bed share, right? If it’s only the absolute risk that counts — as implied by breastfeeding researchers — that’s the inevitable conclusion.

How about formula feeding? Breastfeeding decreases the risk of SIDS, but the absolute risk is low in any case. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies was referenced by Dr. Platt above.

Here’s a chart from the study:

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Notice that the absolute risk of SIDS from formula feeding without bed sharing is LOWER that the absolute risk of breastfeeding with bed sharing. So are mothers who formula feed without bed sharing better mothers than those who breastfeed and bed share? If it’s the absolute risk that counts — as implied by breastfeeding researchers — that’s the inevitable conclusion.

How about homebirth? The absolute risk of death from homebirth with an American homebirth midwife was found to be 5.6/1000 (1 in 179) in a 2012 analysis of Oregon state data. That’s more than 100X higher than the risk of death from bed sharing while breastfeeding. If it’s the absolute risk of death that counts, those women are monsters.

The NPR piece suggests:

…[A]ll bed-sharing is not the same. It doesn’t add the same amount of risk for all families. And so perhaps recommendations about it shouldn’t be the same? Maybe they should be tailored for each family and their circumstances?

How ironic! Those who insist that bed sharing recommendations should be tailored to individual families are often the same people who think that infant feeding recommendations should NOT be tailored for each family and their circumstances; they believe that every family should received the same recommendation that breastfeeding is best for every baby even though that’s obviously untrue.

But let’s get back to the original question: when is it okay to risk a baby’s death? Is the relative risk irrelevant? Is it only the absolute risk that counts? Who gets to decide?

Please share your thoughts in the comment section.

  • Peter Harris

    “When is it okay to risk a baby’s death?”

    After you’ve read all the twisted and distorted lies and misinformation on this website.

  • Anna Lee

    I can see that theoretically the absolute risk is low, but isn’t even 1 baby dying too much? Especially when what the babies are dying of is extremely extremely preventable (I.e., having them sleep on a safe sleep surface like a crib, pack’n play, or bassinet)? How terrible would someone feel as a parent if they are that 1 in 16,400 whose baby died due to co-sleeping?

    I don’t think it is okay to risk a baby’s death simply for co-sleeping or bed sharing’s sake. We as parents have a choice on how to keep our children safe — and our children (especially newborns) are 100% reliant on us. So, I think it is Neither wise nor healthy to co-sleep with a baby for OUR convenience/closeness/breastfeeding/whatever when it puts the baby at risk of injury or death.

  • Dane

    “For babies older than 3 months of age, there was no detectable increased risk of SIDS among families that practiced bed-sharing, in the absence of other hazards.”

    Why is the term ‘SIDS’ used when they’re talking about an identifiable manner of death?

  • Zornorph

    I don’t know why people who want to bedshare don’t just do what I did. I had him next to me in a bassinet with firm sides. He was within reach of me, but it would have been impossible for me to roll onto him. Granted, it was just us in a king size bed so plenty of room, but it seemed the best solution. That was only early on, though, soon he went in the crib (which was right next to my bed so again, he was very close to me and separated only by the rails of the crib – I could reach out and touch him.

    • Merrie

      It’s not considered safe to put a child bed on the parents’ sleeping surface. The mattress can dip–it’s too soft. Sleep positioners aren’t good either. You can get a bassinet and put it next to the adult bed if you want the baby right there.

  • The Bofa on the Sofa

    We want to talk about absolute risk? OK.

    It’s been a while since I’ve brought up drunk driving, but let’s do that again. Drunk driving is bad, right? It’s dangerous. It kills. Thousands of people die in drunk driving accidents each year. There are two million car accidents involving drunk drivers, and 1 million DUIs. We all agree on that drunk driving is bad, right? But how risky is it?

    According to the US DOT estimates, there are 27000 drunk driving miles for every DUI. Put that with the stats above, and the numbers are mind-boggling. 27 billion miles of drunk driving each year!

    OK, if we estimate that the average length of a drunken drive is maybe 8 miles, that would mean that there are 3.4 billion times where someone drives drunk each year.

    With 10000 drunk driving accident deaths (the number for recent years) that means a fatality rate of 3 deaths per million times. In terms of DUI, the rate is 1/3400 (I can’t find how many non-fatal accidents are caused by drunk driving, but if I remember right, it’s about 1/2 of the number of DUIs, so a rate of something like 1/6800)

    So from an absolute rate perspective, a single drunken drive is not that bad. The chance of death is only 3/million. Even the chance of an accident is “only” 1/7000. No, the cost of drunk driving is not because of the risk, it’s because of the prevalence. 27 billion miles per year.

    Now, it’s not fair to compare the risk per incidence to the risk over a period of time. I don’t know how long that period of co-sleeping is to get to that 1/16400 risk, but if we assume that it corresponds to 6 months of co-sleeping, it puts the risk at about 1/3 million per night. So about 10 times safer than drunk driving.

    So a night of co-sleeping isn’t going to be much of a risk. Like drunk driving, the risk that results comes from doing it a lot. But the same can be said for drunk driving, and no one thinks that an occasional drunk drive is acceptable.

    • As mabelcruet shared below, quite a number of bedsharing fatalities occur with unplanned bedsharing. On the other hand, I don’t think drunk driving shows the same pattern, and people who drive drunk tend to drive drunk a lot over a long period; the risk of bedsharing is limited to a period of months.

      So, I don’t think the situation is quite analogous; also, with bedsharing there is a benefit hoped for (breastfeeding or more sleep), and so some rationale for the decision, as poor as the rationale may be.

      • The Bofa on the Sofa

        On the other hand, I don’t think drunk driving shows the same pattern, and people who drive drunk tend to drive drunk a lot over a long period; the risk of bedsharing is limited to a period of months.

        But that all depends on how long the activity is happening. I don’t like stats like that, because they are dependent on way too many factors. For example, consider birth control. Too often, the success rate for birth control is defined as “how many babies were born in the course of a year using that method with normal use.” But that doesn’t apply to everyone. For example, if a woman diligently uses the pill, the risk for a normal population where there are lapses in pill usage don’t apply. Similarly, if the risk is based on sex frequency of twice a week, then it doesn’t apply to couples that only have sex twice a month.

        That’s why I break it down in terms of “per event.” I don’t care if most people who drive drunk do it over a longer period, because the question is, if I am drunk and going to drive home, what is my risk? The risk for an “average” drunk driver over a year doesn’t matter at that point. Similarly, when it comes to bed sharing, the question is, how often are you doing it? If it is once, then the risk is absolutely tiny. You do it over a more extended time, and the risk increases. That is exactly the point of my comment.

        And there is absolutely rationale for driving drunk. It’s cheaper than a cab, it’s more convenient because you don’t have to disturb someone else, etc. As you say, they are poor reasons to do that, but that is because we have zero tolerance for drunk driving. But make no mistake, that zero tolerance for drunk driving is not based on the absolute risk of driving with a BAC of 0.08%, it’s based on how often people drive with that high of BAC.

        I’ve said this before – homebirth in the US right now hides it’s risks by being a fringe activity. 2% of births are homebirths, which means that a pregnant woman is more likely to be a moon landing hoaxer than a homebirther. Therefore, the absolute number of bad outcomes is relatively small. Dozens of deaths a year, but that’s about it. But if homebirth actually got to be more common, the number of dead babies would far more noticeable. Hundreds of babies would be dying in homebirths, despite the fact that they are no more or less risky. The difference would be in the prevalence.

        This is why it is important when considering the risk of an activity to separate it from the frequency. You need to consider them together to consider the cost, but they are two separate factors.

      • Roadstergal

        “and people who drive drunk tend to drive drunk a lot over a long period”

        Well – people who get caught driving drunk tend to drive drunk a lot over a long period.

  • mabelcruet

    I’ve commented a few times before about this, being a pathologist who does the autopsies on these babies. Firstly, the UK pathology community doesn’t generally use the term SIDS, we prefer SUDI (sudden unexpected death in infancy). There’s data to show that different types of pathologist will ascribe causes of death differently-historically these cases in the UK were autopsied by forensic pathologists, or hospital (NHS) general pathologists and only from the mid-late 70s onwards were paediatric pathologists involved (as the discipline was really only developing around then). The other two groups of pathologists are still involved to a greater or lesser extent depending on location, although the guidance is that any infant death should be examined by a paediatric pathologist. The different groups formulate causes of deaths differently-for example, forensic pathologists favoured terms like ‘interstitial pneumonitis’ which meant the death was classified as infection related, rather than SIDS/SUDI. So getting accurate figures and accurate stats is complicated.

    But generally, the currently accepted model of risk is the ‘triad’ theory. This is the triad of a inherently vulnerable infant, at a vulnerable stage of development, being placed into a vulnerable environment. So the inherent vulnerabilities are babies who were premature, babies who were growth-restricted, twins, complex pregnancy, babies with cardiac anomalies etc. The vulnerable stage of development is about the 3-4th month after birth, and the vulnerable environment related to parental sleeping arrangements, smoking and alcohol use etc.

    It’s a Venn diagram-where all three factors overlap, that is when you are at most risk. So a low weight ex premie is going to be at higher risk than a full term normal weight baby even if they are both in their own crib. A 12 month old infant co-sleeping with parents is not going to be at the same risk as a 3 month old bed sharing. From personal experience, and what the data shows, a significant number of cases are infants when the fatal co-sleeping episode was unplanned. The baby was spontaneously brought into bed with parents, or the parent fell asleep on the sofa unexpectedly. Some of the sleeping arrangements that resulted in death could have been recognised as dangerous had the parents thought it through, but in an unplanned co-sleeping event where sleep overtook them, or they’d been drinking or doing drugs and weren’t capable of objectively planning, that’s the danger point.

    Typical scenarios: baby wouldn’t settle in their cot, dad brought baby into bed, balanced baby on his chest while dad sat semi-upright. Next morning, 2 week old baby found face down on the mattress by dad’s side having rolled off overnight. Baby wedged into position on adult bed with cushions and pillows so that she wouldn’t roll off, unfortunately, the movement of mum’s body pushed her over from her side face down onto the pillow used to wedge her in-suffocation. Parents in double bed-baby laid on their back in the void between the parents pillows at the top of the bed-overnight the movement of parental bodies made the pillows move to meet in the middle covering the baby’s face. Baby brought into bed in the early morning-mum made a sling arrangement with her knees up and the baby laying on top of the sheet facing towards mum-mum then fell asleep, then when she woke up she’d turned over in bed and the baby was trapped and entangled in the sheet between her legs. Dad lay down on the sofa with baby, mum upstairs to have a nap. Baby face down on dad’s chest, dad put his hands on top of the baby’s back to stop them rolling off, not realising that the dead weight on his hands when he fell asleep was enough to stop the baby’s breathing-mechanical asphyxiation. Every pathologist has dozens of these stories.

    It is possible to reduce risk, but co-sleeping needs to be planned and managed considering the bedding, room temperature, parental behaviour etc. If your baby was small and premature and you are a smoker, you are putting your baby at risk by co-sleeping. If your baby was normally grown and term, and you don’t smoke, your risk is reduced. It’s a public health message that is hard to get across because there are so many variations and confounders, so it is easier to say ‘never sleep with your baby’ rather than ‘you can reduce the risks if you do XYZ’.

    • Kim

      Thank you – that’s a really informative post. But I wonder about definitions here. In the situations you describe, such as the baby being face down on the father’s chest, would that be recorded as SIDS/SUDI or as asphyxiation?

      • mabelcruet

        That’s exactly why we prefer the term SUDI-sudden unexpected death in infancy. A SUDI can be unexpected and sudden but natural or unnatural, so the term SUDI is always qualified by a secondary descriptor. We use SUDI, unascertained for the cases where there has been no definite cause determined. For the SUDI cases where a cause of death was determined, it’s recorded as SUDI due to pneumonia, for example. Deciding whether or not asphyxiation has happened can be difficult as there may be no signs-sometimes there are features of definite overlaying like the imprint of parental clothing/buttons on the baby’s face then asphyxiation may be given as a cause of death, but it’s more common for the coroner to record a narrative verdict (SUDI, unascertained but in circumstances where asphyxiation cannot be excluded nor confirmed).

        There was a move at one point to record deaths as SIDS type I or type II. Type I are those where every part of the SIDS definition is met (sudden death of an infant between the age of 1 month and 1 year where a full autopsy examination, death scene examination and appraisal of the circumstances of death has revealed no cause of death), and SIDS type II is those deaths that occur when there are features raising concerns (such as parental bed sharing it drugs) but where it’s not possible to determine what role these played in the death. However, SUDI is a more accurate and flexible diagnosis, and can be used to illustrate genuine uncertainty about the circumstances of death.

        On the whole, in the UK, most coroners tend to record these cosleeping deaths as SUDI unascertained whilst commenting about the possible risks. The fact that we can’t say in a lot of cases exactly what killed the baby has its problems, but writing them off as SIDS gives the impression that this was a natural death, when most of them aren’t entirely natural. It’s not parental blaming and shaming, but we need to highlight that there are risks in some parental choices.

  • Megan

    We are in the midst of this kind of dilemma now. My 2 week old seems to have the same GERD and CMPI issues my middle child had, though not quite as bad (less spit up but just as much pain/wheezing/audible refluxing). We are still working on finding a formula that agrees with him to try to improve symptoms but in the meantime sleep is terrible. He sleeps at most 1-2 hours in his swing and forget lying flat at all. He loves to be on his belly and I have seriously contemplated just letting him even though I know the risk is higher. I have thus far resisted. It’s hard to care for three kids this sleep deprived though.

  • Amazed

    When is it OK to risk a baby’s death? Why, when it lurks close by anyway, in the danger of no one sleeping. You do what you can do to reduce the risk because sleep deprivation is very dangerous to everyone around. It’s literally a matter of life and death.

    But share a bed with your baby because all babies need to feel their parents close by and that’s what good parents do and it encourages bonding? Hell, not. And yes, that’s what my friend with the preterm baby – she came home two days ago, hurrah! – got advised by her SIL, a mother of two month old as well. She only stared at her and said, WTF? They gave me a baby who has learned to sleep on her own and I’m supposed to take her in my bed?

    Who gives such an advice? To take a tiny being that is, at best 2/3 of the weight of a healthy term newborn to your bed in order to be a good mother without even giving her the chance to try and sleep in a crib? Well, someone who has been “educated” about the joys of natural motherhood, of course!

    I’ve also heard that it helps breastfeeding and whatnot. Now, this is a line that, IMO, should not be crossed. Sleep deprivation is one thing. But take a tiny being that you may overlay (no, I don’t believe that mom’s instincts will let her magically know when there is such a danger and wake up) because you cannot have the horror of a bottle given by Dad during a midnight feed – no. It’s different from saving sleep and sanity. Taking a risk to actually kill your child in order to exclusively breastfeed them seems… weird. But then, people don’t believe such a risk exists, not about THEM. It’s the same as homebirth and breastfeeding – if I do everything right, it ain’t gonna happen. I understand the appeal of such thinking, actually, but at one point we have to look reality in the face straight and honest, see the risk and assess it.

    • Who?

      Exactly so, on all points.

      I wonder if the same folk who believe they will never overlay their baby also believe they will never cause a car accident, leave the iron on accidentally, or ever, ever have a moment of inattention leading to a potential disaster.

    • Empress of the Iguana People

      Aye. Both my kids were just fine sleeping on their own and in fact my younger child preferred it. 2 weeks old and we figured out she fell asleep easier on a blanket on the floor than in our arms. Near us, yes. On top of us, no. I’m just sensitive about bedsharing with the eldest.

    • Kim

      I’d like to suggest an alternative view here, which is that for some parents the benefits of co-sleeping outweigh the very small risk (i.e. assuming parents aren’t smokers, or haven’t drunk, and are not putting the baby under a heavy duvet etc). It might be that when you and the baby share a bed, you both have a better night’s sleep. And if you have a good night’s sleep, that makes you less irritable and better able to function in the daytime, and in turn that makes you a better parent. So I don’t think it’s clear-cut. You can’t eliminate risk altogether as a parent. You just do the best you can, weighing up the pros and cons as you go.

    • Mimc

      Even if you don’t want to have dad give a bottle you can still be safe. When I was still attempting to breastfeed I’d wake my husband if I felt there was a risk of me falling asleep. He could help me stay awake or move the baby to a safe location if I did dose off. I did the same for him sometimes too when we switched to bottles.

  • I’m wondering why not just put a little crib thingy right next to your bed? That way baby’s right there within easy reach, but not at risk of getting rolled over on.

    Beyond that, why take the risk?

    • Lilly de Lure

      I was wondering about that – its what I did with my son and it worked a treat.

      • It just seems… reasonable.

        • Lilly de Lure

          True, but to be fair reasonable baby sleeping arrangements are somewhat contingent on having a reasonable baby. I’m aware I was lucky enough to have one of those (at least as far as sleeping was concerned) but I’m very aware that some babies simply will not sleep in a crib/ moses basket no matter how close to your bed it actually is. If you’ve got such a baby the risk-reward situation is different, particularly if you feel you are at risk of nodding off on the sofa with the baby (the riskiest scenario of all) because neither of you got any sleep the night before because the baby won’t sleep unless they are in your bed, at which point planned co-sleeping is almost certainly the safest (and most sanity preserving) option. As with just about everything to do with parenting, risk factors are going to vary for different people and there is rarely if ever one “right” solution that is genuinely the best for everyone.

    • Empress of the Iguana People

      There was a picture someone in my duedate group posted. The baby’d rolled right out and into the middle of the bed. The parents were still awake, but it made my PPDepressed self nervous.

  • Sue

    There’s also another aspect: which of these risks is easily modifiable?

    The baby’s intrinsic risk is related to features like prematurity or other co-morbidities – so, not modifiable by the parent.

    Factors like smoking and alcohol use are certainly modifiable, but not always easily.

    The choice of co-sleeping vs cot in the room is very simple to achieve, with essentially no down-side.

  • Who?

    The absolute risk gives pause for thought, as does the conditioning about driving with kids.

    I’m trying to imagine a situation in which I would agree to take an unrestrained baby on a car trip, no matter how short. I came up with the need to get to hospital with a third person, who will certainly die if they don’t move now, and the only vehicle available is one without a car seat ie not the vehicle the baby arrived in.

    What if there is a safe place ie cot in which to leave the baby in the unoccupied house? Would the baby be safer in its cot, for say an hour (drop person to hospital, come straight back for baby) than it would be in the car? Or is the trip in the car, unrestrained, the safer choice? I feel like there is no 100% good decision.

    I feel like I might, if I knew I could get someone to the house pretty quickly, leave baby in the cot. Particularly if I have to drive and my in extremis third person is in no state to keep an eye on baby in the car.

    • Ezekiel Stephans was driven to a naturopath’s office on a mattress because he was too stiff to fit his car seat. Of course, the Stephans aren’t the greatest example of reasonable parenting….

      • Who?

        I forgot about them-the mattress was a caring touch, don’t you think? (That was sarcasm, in case it’s not clear).

        I don’t care for conundrums, particularly life and death ones.

      • Gæst

        That for me would have been a 911 call! And then, sure, if it would take too long for an ambulance to reach me I’d risk it, but where I live that would be highly unlikely.

        • Who?

          That child should have been driven to the doctor when his body would still bend.

          • He certainly should. The Stephanses are getting another trial, did you hear? That poor kid.

          • Who?

            I did. The legal system will do its thing, they and everyone else will still know what choices they made.

            The child will still be dead.

          • Gæst

            For sure.

    • Gæst

      You would have to include the risk of being arrested for child endangerment if it was found out that you left a baby home alone. It’s legal to take a taxi in NYC with a child not in a car seat, and although some people deplore it, I was relieve when I learned it because I was really stressed about how I would get to the hospital in the middle of the night with two babies and two car seats and I guess also a stroller because how could I carry all that? Luckily it never happened, but that was the only scenario I could imagine taking the babies in a car without spending half an hour installing car seats in a cab first. Luckily my only two ER visits happened in the daytime when I was able to enlist the help of non-sleeping people to watch one kid.

      • Who?

        There would be some pain somewhere, no question-a fine and kick up the butt would be a (fairly small) cost of doing business I think.

        It’s a pretty unlikely scenario-we live close to the CBD in an area with ambulances, doctors and hospitals all around, but as a thought exercise about absolute risk I thought it was interesting.

      • Tigger_the_Wing

        When I was a taxi driver, I had car seats available for people without them. I was so used to mounting them either way round (they were reversible, for different ages of baby) that I could change the shoulder heights of the straps in both seats, and fit both, in under five minutes. And that was in the nineties, before Isofix. I’m horrified at the number of taxi businesses that still don’t have child seats available, but also horrified at the number of parents who would carry their newborn out of the hospital in a car seat (hospital policy), and then when they got to the taxi, put the seat in the boot and climb into the back of the car with the baby unrestrained on the unrestrained mother’s lap.

        • Gæst

          That’s awesome that you had seats and knew how to use them. Most services can provide one car or booster seat now, but two or more is iffy, and every driver I’ve had has had me install them myself (for liability reasons, I’m sure, but it’s a car and a seat I’ve never laid eyes on before!). I certainly did not put the car seat in the trunk when I took my babies home from the hospital! But I couldn’t practice the install in advance to be sure I had it right or anything.

          I managed to never take my kids in a cab without proper restraints, and now they are big enough for portable boosters. It was a huge lifestyle adjustment, though, to go from relatively free movement throughout the city to being limited to elevator subway stations and where we could walk in the neighborhood (twins are much harder than singletons as a single parent using public transpo). But I needed to know that in an emergency where there wasn’t time to fiddle with two car seat installations and dragging the seats around at the other end, there was a way to get to the ER.

    • Empress of the Iguana People

      my eldest was only in the spica cast for a month and we didn’t have a car anyway, so purchasing a spica cast carseat was impractical. Except that he had to get to and from the hospital for xrays and stuff.

  • Amy Tuteur, MD

    I don’t think that people who bed share are bad people. It’s reasonable to investigate a risk, decide that it is very low and then choose to accept it.

    My concern is that people who want to promote breastfeeding are not honest about how the risk of bed sharing compares with other risks. We obsess about the risk of not using a car seat (in some places it’s against the law) yet the risk of bed sharing is the same or higher. Lactivists obsess about the “risks” of formula feeding and shame formula feeding mothers when the risk of bed sharing is higher than the risk of formula feeding. Mothers deserve factual information about all risks, not articles trying to shame women about some risks while excusing other equal or greater risks.

    • Jessica

      Absolutely agree. I am in the midst of transitioning my 4 month old to formula and I feel very comfortable with that from a SIDS risk perspective because he is full term and high birth weight, with no smoking in the house, who sleeps in a crib on his back with a pacifier in our room (in a high SES household). So I know his absolute risk is still very very low even without breastfeeding.

    • Gæst

      I would have liked to have seen the absolute risks when my kids were infants. I didn’t bed share, but in the beginning I was so terrified of SIDS I kept waking up to check whether they were still breathing. Maybe it would have helped me relax if I knew just how rare it was for a non-cosleeping infant.

      • Lilly de Lure

        Me too! My son was a champion little sleeper from quite an early age but I still got very little sleep as I woke up every hour or so throughout the night to check he was still breathing until he was nearly 1.

    • Sue

      Great points, Amy. We are notoriously bad at estimating risk, and tend to make distorted decisions if given false information, such as about baby feeding.

      Of course, lactivism and extreme “attachment” are not about risk at all, but about ideology.

  • Jessica

    I think absolute risk matters. Honestly, the SIDS recommendations feel like a lot of rules to protect against a very uncommon outcome, particularly for healthy term infants. I would have loved some guidance on what is more or less risky (my son sometimes naps, supervised, in his carseat which is against recommendations though low absolute risk given the supervision). Without some sense of absolute risk, people engage in all kinds of dangerous situations (falling asleep on coach while breastfeeding, etc) that they could better plan for with understanding of the absolute risk for each point.

    • CanDoc

      ^ Agree.
      We bed shared with both of our kids as babies from about 8 weeks old onward because I was too exhausted to do anything else, with an underfed baby who (in retrospect) should have received formula, who cried constantly if he wasn’t nursing. Everyone is just doing the best they can in the situation they’re in.

  • Generally, I think that within certain parameters (ie, not neglect or abuse), a parent should have the right to make decisions for their child. This might include decisions that will increase the risk of death slightly, such as having an amniocentesis, not following one or more safe sleep guidelines, forward-facing a child who still fits the backward-facing size and weight limits, and maybe other things.

    The magnitude of risk matters–both absolute and relative. Something inherently risky (such as birth, in my opinion) should be approached with as much risk reduction as one can manage. Something inherently less risky might lend itself to flexibility of risk.

    The other half of the equation is benefit. What advantages are there to be derived from taking a given risk? What are the odds of the good outcome which you hope for by taking the risk?

    All of this depends, however, on accurate information presented in an unbiased manner. People’s situations are NOT one size fits all, but to arrive at the best decision they must know the risks and benefits well. Biased articles promoting bedsharing as a help to breastfeeding are not doing this. And parents need to know that if they choose to bedshare, the risk for their beloved child’s death goes up, especially at under 3 months of age.

  • CSN0116

    This is such a complicated topic. Here’s the thing: (nearly) every parent I know has broken safe sleep “rules” with their infant. Some do it rarely. Some do it more frequently. Some do it out of necessity. And some do it to make life easier. But the fact that the majority violate the rules – and I will boldly predict that if an anonymous survey was distributed we would learn that the majority have been in willful violation at one time or another (yet SIDS decreased regardless) – tells us that the rules sound good on paper, but are not applicable to real life. Shouting “back to sleep!” and “sleep alone!” doesn’t mean much on a case-by-case, complicated basis.

    I demonize people representing the facts as lies and bragging about it – yes. But I don’t demonize the people violating safe sleep on the sly to survive another night.

    It’s one of those “all things equal the safe sleep rules are best” — but enter in 1,000+ scenarios and it goes to shit. My twins should have rear faced until age two, but vomited within 10 minutes of travel when rear-facing. Forward facing allowed them to travel in a car for at least 30 minutes before needing to stop. Back is best, but for my reflux baby, it sucked. He cried inconsolably and was awake constantly. Belly sleeping on a slight incline worked instantly and allowed him to rest for more than 30 minutes at a time.

    We are not meeting the needs of babies and families with this catch-all compartmentalized advice with total disregard for “what-if” scenarios that are more common than they are rare. I don’t have the answer to better safe sleep education, but this isn’t working [insert the rise and mass sale of Rock n Plays where thousands (millions?) of babies are now slept because parents see how well they sleep on the incline]. It’s giving rise to woo and inaccurate information with the only counter argument being the same old adage that isn’t working for many families.

    • J.B.

      When we had the second kid, the pediatrician reminded us of the recommendations and told us “you do what you have to to survive”.

  • just me

    It’s never ok. No one (other than maybe people in a refugee camp or homeless shelter) “must” bedshare. It’s a (foolish) choice. My first was a terrible sleeper. The attachment types in my parent baby group urged me to cosleep “oh it’s only risky if you smoke etc”. I called BS and managed to survive (without bedsharing) until my baby was old enough to sleep train (at which point baby became an excellent sleeper).

    • J.B.

      I get that, but sleep deprivation with my first led to PPA and several almost accidents.

  • Allison

    My biggest concern is that some babies simply do not sleep well. And when we tell parents you must never, ever bedshare, we increase the risk of a desperately exhausted parent falling asleep with a colicky baby on the couch or in the recliner, which is a far, far bigger risk of falls and suffocation. (Death by suffocation is not the same thing as death by SIDS. SIDS has no obvious cause; suffocation, the cause of death is… suffocation. Bedsharing doesn’t increase the risk of death by SIDS in the absence of respiratory factors like second and thirdhand smoke, it increases the risk of death by suffocation.)

    I’ve been that desperately exhausted parent, and I’ve caught myself dozing off on the futon with a baby who had been fussing for hours despite my trying everything I knew, who had *finally* latched and fallen asleep. And at that point, I did the only thing that made sense. I took him back to the bedroom, I stripped every blanket, comforter, and pillow off the bed until there was nothing but a sheet, and I stuck a 2-by-4 in the gap between the mattress and the wall. The risk of his suffocating on a plain, flat mattress next to me was far, far less than the risk of his suffocating slipping out of the crook of my arm and getting trapped between me and the back of the futon. Was it ideal? No. But that night, it was the safest I could make him.

    • Sue

      Allison – I don’t think anyone can judge others for those best-I-can-do-tonight compromises – especially since you went to the lengths of removing bed covers.

      That’s different to routinely placing a newborn in an unmodified shared bed.

      • AnnaPDE

        Ah, you don’t think anyone could judge her? Then just look at “just me” one comment above.

  • The Kids Aren’t AltRight

    I think the “who gets to decide” is the important question. I plan to drive around with my baby, even though it will risk her death because the alternative is unworkable. For the most part, parents should be informed of the risk put into context and people will evaluate that risk differently based in their lifestyle, values, etc. There is a certain point where ignoring risk becomes neglect. Not sure where the line is, but it is probably much more severe behavior than bed sharing or formula feeding.

    A lot of the problem with bed sharing and homebirth and other propoganda is that advocates often pretend that the risks are all a lie or that they don’t pertain to someone as special as you, and the people who buy in to the bullshit aren’t making decisions with their eyes wide open.

  • Cartman36

    Aren’t these the same people who think women should breastfeed exclusively for 6 months no matter how inconvenient and painful because MAYBE it will reduce your child’s relative risk of developing type 2 diabetes by 47% (https://www.telegraph.co.uk/science/2018/01/16/breastfeeding-six-months-slashes-type-2-diabetes-risk-47-per/).

    But increasing their risk of death by bedsharing is OK??? I’m so confused.

  • Montserrat Blanco

    When science shows what you want you justify everything with science. When science does not show what you want you squeeze the data until you find a small “good” group that justifies what you want. Great.

  • mjd3

    I think the issue is that baby sleep is far more complex and individual than the decision to put the baby in a carseat, or to formula feed. Some babies just do not sleep – and it doesn’t really help anyone to just say “Back to Sleep! Baby sleeps in the crib!” With only slogans, it starts to become more likely that exhausted parents will fall asleep accidentally with the baby on the couch, or that solutions like infant sleep positioners will create even more risk. Or the parents are so sleep deprived they crash the car, or forget the baby in a hot car … I think this is a good sort of “shared decisionmaking” opportunity, where the doctor informs the family of the risks, and they discuss all aspects of the problem.

  • fiftyfifty1

    I think it should say “So are mother who formula feed without BEDSHARING better..”

    • Amy Tuteur, MD

      Thanks! Fixed it.

  • swbarnes2

    Another thing about that chart, the lightning thing is risk that you face every day of a 72 year or whatever lifetime. The SIDS risk is over the course of a matter of months. The risk of drowning, or being in a car accident, or being hit by lightning in a 12 month interval are much smaller than they are on that chart, and much smaller than the SIDS rates.

    • mjd3

      Is that true? We’d have to see the articles. Isn’t risk usually expressed in “person years”?

      • swbarnes2

        The lightning one is specific that it’s lifetime. The sourcing in the NPR article isn’t specific enough . NOAA says that on average 51 people are killed in the US by lightning, and fatalities are 9-10% of the strikes, so about 500 people struck a year.

  • crazy mama, PhD

    I think it’s important to talk about risk factors in bedsharing (i.e., if you must bedshare, here’s how to do so more safely), but I’m bothered by NPR’s “low-risk baby” vs. “high-risk baby” formulation. I’m thinking back to last week’s post about real-world evidence and how some types of birth control are much less effective in practice than in studies, because humans screw up. How often do parents who are otherwise low-risk bedsharers screw up? (And I don’t mean having a bunch of drinks before bed, I mean stuff like taking an allergy medication that has unanticipated effects on how deeply you sleep.)

  • Roadstergal

    I’m not going to weigh in on the conclusion, but I think the comparison to other relative risks is critical context.

    Also, they should divvy out peanut allergies with EBF vs 4-6 month introduction of the allergen.

  • Um. I do think the absolute risk matters, and so yes, I would say that some decisions that increase a baby’s risk of death could be acceptable, depending on the circumstances.

    (I let my first sleep on her tummy because she wouldn’t sleep longer than an hour otherwise, and it was destroying me. I had nightmares about her dying from SIDS, but took the risk anyway because the current state was insupportable.)

    But relative risk should not be ignored when one makes these calculations, and accurate information about risks and benefits is essential. Breastfeeding is not a benefit that outweighs the risk of SIDS, in my opinion.

    • Empress of the Iguana People

      Kind of what happened when we bedshared with my eldest for a couple months. I just could not stay awake long enough to feed him at that 3am snack. I tried over and over, but in the end, it was moderately safer to -plan- to bedshare from 3 until 6. (he always started the night in his own crib). Dem took over the 3 am meals with younger child and she never bed shared.

    • FormerPhysicist

      Yes. After the umpteenth time I fell asleep and dropped the infant while trying to feed her in the middle of the night, it was obvious that we needed to reduce that risk and planning on bedsharing might be a reasonable alternate risk – after we minimized the risk of bedsharing.

    • AnnaPDE

      Yes, absolute risk matters.
      I seem to recall this being recognised in that post about risks of CS vs vaginal birth, where it was pointed out that the large relative increase in subsequent placental problems for CS still only amounted to very few cases, whereas a moderate percentage change in pelvic floor damage actually makes a big absolute difference.
      This argument was accepted to make sense back then. Same standards apply here.

  • Madtowngirl

    I admit it. I bedshare with my toddler. I hate that it happens, but it does.

    But we DID NOT do it before she was a year old. I am normally a light sleeper, but that deprivation of sleep in those early months I would fall asleep as soon as my head hit the pillow. The reality is that it would have been super easy to roll on to her and smother her and not wake up. And i don’t do drugs, and I was too tired to drink. No to mention, our dogs sleep with us and would have stomped all over her. I think it is so dangerous to recommend bedsharing in those early months.

    • Steph858

      I also bedshared with my toddler. Can’t remember exactly what age we started, but it was when he started climbing out of his crib by himself. Once he could do that, there was really no point in trying to force him to sleep in his crib, because in 5 minutes flat he would have climbed out of the crib and started trying to climb up onto my bed. At which point it could be argued that this scenario was more dangerous than just letting him sleep in the ‘big bed’ in the first place, because he’d start trying to use random nearby objects as ‘big bed ladders’ …

      But since he was a preemie, those NPR folk already dumped me in the ‘wrong kind of parents’ pile. Guess I might as well have a pint and a fag while I’m there, since according to their oh-so-scientific chart my risk level will remain the same however many additional risk factors I pile on.

      • Gæst

        I know exactly when my toddlers started beds haring with me: when I took the baby gate off their bedroom door and they were able to get up and climb into my bed in the middle of the night!

        • Mishimoo

          My nearly 5 year old has started climbing in on my side most nights, thankfully he goes back to sleep instead of wanting to play. It does get squishy though – the dogs climb up in the night, and they’re pretty big. Then kiddo hops in about 3am, and sometimes he brings a cat with him.

    • Amy Tuteur, MD

      It’s not a risk for toddlers.

    • Kathleen

      The most risk is the earliest babies. Right when parents are most exhausted.