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Original Investigation |

Trends and Factors Associated With Infant Bed Sharing, 1993-2010:  The National Infant Sleep Position Study

Eve R. Colson, MD1; Marian Willinger, PhD2; Denis Rybin, MS3; Timothy Heeren, PhD4; Lauren A. Smith, MD, MPH5,6; George Lister, MD1; Michael J. Corwin, MD7
[+] Author Affiliations
1Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
2Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
3Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
4Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
5Massachusetts Department of Public Health, Boston, Massachusetts
6now with Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
7Department of Pediatrics, Boston University School of Medicine, and Slone Epidemiology Center, Boston University, Boston, Massachusetts
JAMA Pediatr. 2013;167(11):1032-1037. doi:10.1001/jamapediatrics.2013.2560.
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Importance  A strong association between infant bed sharing and sudden infant death syndrome or unintentional sleep-related death in infants has been established. Occurrences of unintentional sleep-related deaths among infants appear to be increasing.

Objectives  To determine the trends and factors associated with infant bed sharing from 1993 through 2010, including the association of physician advice on bed sharing.

Design  National Infant Sleep Position study conducted with annual telephone surveys.

Setting  The 48 contiguous states.

Participants  Nighttime caregivers of infants born within 7 months of each survey administration. Approximately 1000 interviews were completed annually.

Main Outcomes and Measures  Infant bed sharing as a usual practice.

Results  Of 18 986 participants, 11.2% reported an infant sharing a bed as a usual practice. Bed sharing increased from 1993 (6.5%) to 2010 (13.5%). Although bed sharing increased significantly among white respondents from 1993 to 2000 (P < .001), the increase from 2001 to 2010 was not significant (P = .48). Black and Hispanic respondents reported an increase in bed sharing throughout the study period, with no difference between the earlier and later periods (P = .63 and P = .77, respectively). After accounting for the study year, factors associated with increase in infant bed sharing as a usual practice included maternal educational level of less than high school compared with college or greater (adjusted odds ratio, 1.42 [95% CI, 1.12-1.79]); black (3.47 [2.97-4.05]), Hispanic (1.33 [1.10-1.61]), and other (2.46 [2.03-2.97]) maternal race or ethnicity compared with white race; household income of less than $20 000 (1.69 [1.44-1.99]) and $20 000 to $50 000 (1.29 [1.14-1.45]) compared with greater than $50 000; living in the West (1.61 [1.38-1.88]) or the South (1.47 [1.30-1.66]) compared with the Midwest; infants younger than 8 weeks (1.45 [1.21-1.73]) or ages 8 to 15 weeks (1.31 [1.17-1.45]) compared with 16 weeks or older; and being born prematurely compared with full-term (1.41 [1.22-1.62]). Almost 46% of the participants reported talking to a physician about bed sharing. Compared with those who did not receive advice from a physician, those who reported their physicians had a negative attitude were less likely to have the infant share a bed (adjusted odds ratio, 0.66 [95% CI, 0.53-0.82]), whereas a neutral attitude was associated with increased bed sharing (1.38 [1.05-1.80]).

Conclusions and Relevance  Our finding of a continual increase in bed sharing throughout the study period among black and Hispanic infants suggests that the current American Academy of Pediatrics recommendation about bed sharing is not universally followed. The factors associated with infant bed sharing may be useful in evaluating the impact of a broad intervention to change behavior.

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Figure 1.
Trends in Infant Bed Sharing as a Usual Practice

Data depict 3-year moving average values for white, black, and Hispanic participants.

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Figure 2.
Physician Advice and Participant Report of Infant Bed Sharing as a Usual Practice

Classification of physician advice is described in the “Factors Associated With Infant Bed Sharing as a Usual Practice” subsection of the “Results” section.aAdjusted odds ratio (AOR) of infant bed sharing as a usual practice compared with physician advice, 0.66 (95% CI, 0.53-0.82).bAOR, 1.38 (95% CI, 1.05-1.80).cAOR, 1.19 (95% CI, 0.76-1.88).

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Bedsharing and SIDS
Posted on February 5, 2014
Elizabeth S. Bernstein
unaffiliated author
Conflict of Interest: None Declared
“Strong associations between bed-sharing and sudden infant death syndrome” have been established, the authors say. Citing two 2009 studies for this proposition—Blair et al. (1) and Vennemann et al. (2) —they go on to assume that the only appropriate response to increased evidence of bed-sharing is to step up efforts to discourage it. Yet it remains a distinct possibility, which no study has disproven, that the family bed might be the safest primary sleep location for infants of sober, non-smoking parents. The Blair et al. study (1) found that where parents had not taken drugs or consumed more than two drinks, sharing a bed with the infant showed no increased risk of infant death. The authors in fact cautioned that “Any advice to discourage bed sharing may carry with it the danger of tired parents feeding their baby on a sofa, which carries a much greater risk than cosleeping in the parents’ bed.”As for the Vennemann et al. article (2), it exemplifies a critical limitation which not a single study relied on by the AAP (3) has overcome. This is the failure to distinguish between primary and occasional bed-sharing. The concern is not that parents who bed-share occasionally somehow put their infants at greater risk when they do so. It is that among occasional bed-sharers, the decision to have the infant in the parental bed at any given moment might be influenced by the fact that the infant seems unwell or is unusually difficult to settle. It might, in other words, be some condition of the infant which elevates both the probability of the infant being taken into the parental bed and the risk of SIDS. In fact the Vennemann at al. analysis cited found no increased incidence of SIDS among primary bed-sharers, those who indicated “parental bed” as the place the child usually slept. Only when the authors classified as “usual” bed-sharers a much larger group who responded that their babies spent some interval in the parental bed either “sometimes” or “every night,” did they see that SIDS cases were somewhat more likely to be in the parental bed at last sleep than were controls during reference sleep. But this is exactly what might be expected in the case of parents who regularly “flexed” their sleeping arrangements and an infant facing some sort of health challenge, even if that challenge were subtle or the parents’ awareness of it subliminal.The continued calls to uniformly discourage cosleeping are unsupported. They do a real disservice to parents. (1) Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in South West England. BMJ. 2009;339:b3666. doi:10.1136/bmj.b3666.(2) Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Sauerland C, Mitchell EA; GeSID Study Group. Sleep environment risk factors for sudden infant death syndrome: the German Sudden Infant Death Syndrome Study. Pediatrics. 2009;123(4):1162-1170. doi:10.1542/peds.2008-0505.(3) Moon RY; Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011; 128:e1341-e1367.doi:10.1542/peds.2011-2285.
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