separate room in a bed (crib) by his or herself.  This practice was felt not only to be safer for the infant (i.e. protect against SIDS) but to foster the western philosophy where individualism and independence are traits to be encouraged and prized.  With the increased effort to promote breastfeeding and the recognition that co-sleeping (at least in the same room as an adult) protected against SIDS, the AAP now recommends that an infant sleep near the mother but not on the same surface.  The 2005 AAP Policy Statement on SIDS admits the topic of bed sharing is controversial and suggest the risk of SIDS while bed sharing is greatest when there is another risk factor such as maternal smoking during pregnancy, sleeping on a sofa, etc.³   

Dr. James McKenna, an anthropologist who studies mothers and their infants in sleep labs,  found that infants, when sharing a bed with their mother, aroused more frequently and breastfed twice as long on those nights as compared to nights when they were sleeping alone.  In this study the co-bedding mother and infant got overall more sleep but the sleep is a lighter stage 1 and 2 sleep with more arousals for both throughout the night.⁴  He argues that the AAP when making their recommendations did not consider all of the available data, but rather relied and a few epidemiological studies.  He also argues that his data support studies that suggest co-sleeping protects against SIDS.

Current nomenclature makes a distinction between co-sleeping and bed sharing.  Co-sleeping refers to any sleep arrangement that allows an infant to sleep in close social or physical contact with a caregiver.  Co-bedding or bed sharing, where an infant sleeps on the same surface as the mother, is one form of co-sleeping.  Studies have shown that co-sleeping promotes breastfeeding and reduces the incidence of SIDS.³   The work of Dr. McKenna suggests that safe co-bedding is even more beneficial in the promotion of breastfeeding and may also protect against SIDS.  Others, however, disagree and feel co-bedding puts an infant in the first 4 months of life at an increased risk of SIDS.⁵

Formula fed babies appear to need fewer feedings through the night than breastfed infants.  Some experts, and research on stomach emptying times ⁶, suggest that breastmilk is more easily digested than formula and moves through the GI tract more quickly, thus the breastfeeding infant needs more frequent feeds throughout the day and night to satisfy hunger.  Others speculate that breastfed infants are more prone to develop an association of breastfeeding as a necessary requirement to falling asleep, thus when infants develop better defined sleep stages that include brief periods of waking, they need to breastfeed just to transition back to sleep not necessary to satisfy hunger.  A study by Pinilla et al, however, demonstrated that exclusively breastfed infants can be trained to sleep for at least one five hour stretch by eight weeks of age.  Parents were enrolled in the study before delivery of their infant and divided into two groups of thirteen.⁷    When infants in the treatment group were three weeks of age parents were to give a “focal feed “between 10 pm and midnight, then at the next awakening they were to try and soothe their infant by re-swaddling, patting, diapering, or walking the infant to stretch nighttime feeding intervals by breaking the association between awakening at night and being

fed.  Sleeping through the night was defined as sleeping from midnight to 5 am.  With training, 100% of infants were able sleep uninterrupted for five hours by eight weeks of age as defined by sleeping for the five hours on two of the three nights sleep diaries were kept.   It should be kept in mind, however, that continued night time feeds are associated with longer duration of breastfeeding and a greater supply of breastmilk.⁸

Before I can help Sarah’s parents I need more information.  What kind of work do they do?  Will mom be returning to work out side of the home and if so when?  What is their breastfeeding plan and if they were to co-bed what would be their goal for having Sarah sleep independently.  In what kind of bed do they sleep?   Is there a family history of SIDS? Do Sarah’s parents smoke or ever drink in bed or take medications to assist with sleep?  

As noted above, Mrs. Perlman plans to exclusively breastfeed for six months but continue breastfeeding for at least one year.  She has arranged a six month maternity leave at which time she will be returning to her position as chief financial officer of a local biotechnology company.  She will need to have the sleep “issues” worked out by then, and does not feel co-bedding is an option when she returns to work. Dad also works outside the home.  They have hired a nanny to come into their home during the day to care for Sarah. They have a firm mattress; do not drink alcoholic beverages before bed or take medications to induce sleep.  They have never smoked cigarettes. There is no family history of SIDS.

I review with Mr. and Mrs. Perlman what is known about sleep patterns in the newborn and that Sarah’s awakening when they put her down is to be expected.  I also share with them my real concerns regarding sleeping on a sofa with an infant being much more dangerous than safe co-bedding.  We review safe co-bedding: 1. firm mattress (no waterbed) 2. no pillows near the baby  or soft comforters  or duvets on the bed  3. no smoking or drinking alcoholic beverages prior to bedtime  4. Sarah needs to sleep on her back when she is not nursing   5. no spaces between the mattress and wall or headboard where Sarah could be trapped.

Sarah’s dad is still uncomfortable with the three of them co-bedding because he is a very sound sleeper and sometimes rolls over and hits his wife with his arm in his sleep.  They decide to put a firm mattress on the bedroom floor where Sarah and her mother to sleep for the next few weeks as Sarah is adjusting to her new environment.

Follow-up via telephone one week later revealed that mom and Sarah were sleeping most nights on a firm mattress on the floor where she would nurse multiple times throughout the night but both quickly return to sleep after each breastfeeding episode.  Sarah was starting to nap for short periods in her bassinette during the day.  Mom was feeling more rested and no longer felt like she had the baby blues.  Mrs. Perlman planned to place Sarah in the bassinette as she would tolerate and I agreed that at the four month visit if still co-bedding, we would discuss strategies to get Sarah to sleep in her bassinette during the night.

Key points:

1. This case illustrates an alarming trend that I am encountering frequently in my practice, and usually

Sleep and the Breastfeeding Baby

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